High Fertility in a High-Risk Environment: a Biocultural Study of Maternal Health in Honduran Miskito Communities

Home , Grisi siknis, Miskito grammar, Natural fertility, Yanomami women

HIGH FERTILITY IN A HIGH-RISK ENVIRONMENT: A BIOCULTURAL STUDY OF MATERNAL HEALTH IN HONDURAN MISKITO COMMUNITIES

DISSERTATION

Presented in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in the Graduate School of The Ohio State University

Shahna L. Arps, M.A.

****

The Ohio State University 2007

Dissertation Committee: Approved by Dr. Douglas E. Crews, Advisor

Dr. Ivy Pike Advisor Dr. Kendra McSweeney Graduate program in Anthropology

Dr. Barbara Piperata

ABSTRACT

This study examines maternal morbidity, mortality, and current health status in coastal Honduran Miskito communities. In this population, widespread poverty, inadequate access to healthcare, high disease loads, and stressors associated with modernization jeopardize women’s health. Individual interviews, anthropometric measurements, and health assessments were conducted for 218 women. Focus group discussions, participant observation, and community-wide surveys of maternal mortality also provide a basis for exploring how interactions among biology, culture, and environment produce variation in reproduction and health. Average fertility rates are high in these communities (TFR = 7.7 live births); however, individual women show substantial variation in the number of offspring they produce (range: 1-14 live births). Women age 45 and older experienced three to fourteen live births. Over 68% of the variation in fertility among women in this sample is explained by maternal age, age at first pregnancy, average breastfeeding duration, birth control use, marriage, and low socioeconomic status. The risk of maternal mortality is also high. Community members reported 55 maternal deaths among their female relatives, most due to preventable causes such as severe bleeding, obstructed/prolonged labor, and infection. Women reported health problems during one out of every four pregnancies, births, and postpartum periods experienced. Over 72% of non-pregnant participants were overweight or obese. Despite adequate calories, micronutrient deficiencies persist. Total prevalence of anemia was 42.5%. The prevalence of high

ii blood pressure and hypertension was 18.1% for systolic blood pressure and 11.4% for diastolic blood pressure. Using a biocultural approach, this study identifies and explores reasons for variation in these maternal health indicators. Because fertility and maternal morbidity and mortality are high, interactions between reproductive measures and maternal health status are highlighted. Risks for poor health are highest among young women, pregnant women, and women who experienced higher morbidity rates during previous pregnancies. Trade-offs between investing in reproduction and maintaining maternal well-being occur because investments in reproductive effort reduce resources available for promoting health and long-term survival. Biodemographic and socioeconomic factors such as age, socioeconomic status, wage earning, meat consumption, and social support also influence women’s risks of poor health outcomes. While some individuals maintain health despite difficult circumstances, inadequate access to material and non-material resources constrains most women’s abilities to buffer their health in this high-risk environment. Understanding human adaptability and limits of adaptability depends on identifying factors related to vulnerability and resilience in marginalized communities like those included here. This study also draws attention to local maternal health needs and provides information necessary to improve health in these communities.

iii Dedicated to the women who shared their life stories with this meriki mairin

iv ACKNOWLEDGMENTS

This dissertation would not have been possible without the help and support of so many different people. First, I would like to thank the women who participated in this research project. They welcomed me into their homes despite my many questions, poking and prodding during health assessments, and fumbling to conduct interviews in their languages. They shared their laughter and grief with me, recounting both humorous stories of growing up and painful memories of the deaths of children, sisters, and mothers. I am grateful for their candor, their patience, and the lessons they have taught me. Women’s strength during their struggles to survive and thrive in spite of difficult living conditions continues to inspire me. I would particularly like to thank my local research assistants Exy Polar, Lastenia Hernandez, and Emelina Castillo. Not only did they help me collect interviews and health assessments, they also turned out to be invaluable informants, and wonderful friends. Our long talks during endless walks from village to village helped me see that despite all of our differences, as women, we do share in common the same fundamental problems, worries, hopes, and dreams. To Doña Exy in particular, thank you for sharing your home with Brian and me and giving us a family in the Mosquitia. I honestly would not have been able to complete this research (or survive for that matter) without your hard work and dedication to your family, friends, and community. Thank you also to Juana, Abacoub, Derwin, and Don Gildo for becoming our extended family.

Funding for this research was provided by The Wenner-Gren Foundation for Anthropological Research. The Office of International Affairs also supported a preliminary trip to Honduras which informed this study’s design. MOPAWI, a development NGO in the Mosquitia and the Honduran Institute of Anthropology and Archaeology deserve thanks for their support and advice before and during data collection. Osvaldo Munguía, the director of MOPAWI, and Carlos Molinero, MOPAWI’s community facilitator, were especially receptive to my research goals and offered important guidance and assistance in the field. I am also grateful to Steve and Jude Collins who let us housesit, invited us for dinner (with vegetables!), shared their pictures, provided conversation in English, and most importantly, offered friendship and kindness. I would also like to thank the many professors who inspired me to become an anthropologist and provided instruction and mentorship through my undergraduate and graduate training. I decided to make a career in anthropology at Ohio University, thanks to my experiences in classes with Dr. Ann Freter-Abrams and Dr. Tibor Koertvelyessy. At The Ohio State University, Dr. Douglas Crews, my advisor, has been instrumental in my graduate training and progress through the program. He has served on all of my committees, from the masters exam to my doctoral committee. Dr. Crews, I appreciate the time you have taken to edit my dissertation chapters!

Likewise, Dr. Ivy Pike offered fascinating courses and seminars that eventually led me to define my research interests and goals. Dr. Pike, thank you for teaching me methods, providing moral support, and most of all for helping me develop my love for theory! I am also grateful to Dr. Kendra McSweeney who offered important advice and contacts for my research in Honduras. She has also been a fantastic mentor and I appreciate her finding me RA appointments to give me breaks from teaching as well as her interest in my research and theoretical perspective. Thank you vi also for many hours of interesting conversation, and collaboration on publications! I would also like to acknowledge all of my committee members, including Dr. Barbara Piperata who most recently agreed to serve on my committee. Thank you all for your interest, advice, and feedback! I would also like to thank some of my fellow graduate students who have become great colleagues and even better friends. Lexine Trask, Jon Racster, and Alyson Young have all been to Honduras with me at one time or another. My favorite thing about all three of you is that we can bounce ideas off of each other, spend hours discussing theory and methods, or completely take a break from Anthropology and just have fun together. Thank you all for being so supportive over the years! I am grateful for your friendship and the memories we have created. My family members deserve more gratitude than I can express, given their unending love and support. To my mother, father, and sisters, thank you for encouraging me to pursue my academic and research interests even when it meant living in a remote region of Central America for a year. I am sorry that you worried in between rare phone calls and emails! I also appreciate your tolerance and patience with me after I returned from Honduras during the “reintegration period” and other stressful times. Mom, dad, Jaimee, Kiki, and Brian – thanks for boosting my confidence whenever I need it most. Brian, thank you most of all, for sharing the adventure with me. Telling stories may be entertaining, but it just is not the same as having someone who remembers the same conditions and unbelievable occurrences. I know that you have made sacrifices so that I could complete this project. I am grateful that you have been willing to endure the hardships of life in the field and the hardships of living with a frazzled graduate student. Thank you for being my partner AND my best friend!

vii VITA

1998…………………………………………………A.B. in Political Science, minor in Anthropology, Ohio University

2000…………………………………………………Graduate Research Associate, Department of Anthropology, The Ohio State University

2001…………………………………………………M.A. in Anthropology, The Ohio State University

2004…………………………………………………Graduate Research Associate, Department of Geography, The Ohio State University

2000- 2007…………………………………………..Graduate Teaching Associate, Department of Anthropology, The Ohio State University

PUBLICATIONS

Arps, S. 2007. Prevalence of anemia and variation in hemoglobin concentration among women in Miskito communities. American Journal of Human Biology 19(2):247.

McSweeney, K. and S. Arps. 2005. A ‘Demographic Turnaround’: The Rapid Growth of Indigenous Populations in Lowland Latin America. Latin American Research Review 40: 1:3-29.

Arps, S. and K. McSweeney. 2004. Demographic trends among lowland indigenous populations in Latin America. American Journal of Human Biology 16 (2): 194.

viii Arps, S. and L. Trask. 2003. Concurrent pregnancy and lactation: a life history perspective. American Journal of Human Biology 15 (2): 255.

FIELDS OF STUDY

Major field: Anthropology

Specializations: Biocultural Anthropology Maternal health Anthropological demographics Fertility and reproduction

ix TABLE OF CONTENTS

Page

Abstract...... ii

Dedication...... iv

Acknowledgments...... v

Vita ...... viii

List of Tables...... xv

List of Figures...... xviii

CHAPTER 1 INTRODUCTION...... 1

1.1 Statement of the problem...... 1

1.2 The Miskito case study...... 5

1.3 Theoretical significance...... 7

1.4 Applied significance...... 8

CHAPTER 2 CULTURAL CONTEXT: COASTAL MISKITO ...... 10 COMMUNITIES IN HONDURAS

2.1 Background information...... 10

2.2 Historical context...... 12

2.3 Current subsistence/economy...... 15

2.4 Residence patterns...... 24

2.5 Population dynamics...... 25

2.6 Previous research regarding health...... 26

2.7 Communities along the Ibans lagoon...... 28

CHAPTER 3 THEORETICAL BACKGROUND AND ...... 33 CONCEPTUAL TOOLS

3.1 Primary research goals and questions...... 33

3.2 An evolutionary perspective on reproduction: Maternal health and fitness...... 35

3.3 Determinants of maternal health and fitness...... 37

3.4 Costs of reproduction...... 41

3.5 Life history theory...... 43

3.6 Life history theory: Maternal investment and reproductive costs...... 45

CHAPTER 4 METHODOLOGY...... 50

4.1 The biocultural research model...... 50

4.2 Project design...... 51

4.3 Focused group discussions...... 55

4.4 Individual interviews...... 56

4.5 Health assessments...... 58

xi 4.6 Follow-up interviews...... 61

4.7 Survey of maternal mortality...... 63

4.8 Data analysis...... 63

CHAPTER 5 THE MISKITO ETHNOMEDICAL SYSTEM...... 74

5.1 Medical pluralism...... 74

5.2 Etiology of siknis...... 74

5.3 Curing and healing illness...... 78

5.4 Perceptions and use of Western biomedicine...... 81

5.5 Pregnancy, childbirth, and the recovery period...... 82

CHAPTER 6 DEMOGRAPHIC INDICATORS OF LIFESTYLE, ...... 87 FERTILITY, AND HEALTH

6.1 Household demography...... 87

6.2 Fertility...... 92

6.3 Health indicators...... 106

CHAPTER 7 BODY COMPOSITION, HEMOGLOBIN ...... 114 CONCENTRATION, AND BLOOD PRESSURE LEVELS

7.1 Body composition...... 114

7.2 Hemoglobin concentration...... 124

7.3 Systolic and diastolic blood pressure...... 133

xii CHAPTER 8 MATERNAL MORTALITY IN COASTAL ...... 140 COMMUNITIES ALONG THE IBANS LAGOON

8.1 Introduction...... 140

8.2 Summary statistics for maternal deaths...... 141

8.3 Lack of adequate economic and healthcare resources...... 146

8.4 Gender inequality...... 149

8.5 Witchcraft and sorcery...... 150

8.6 Conclusions...... 155

CHAPTER 9 DISCUSSION OF RESULTS AND CONCLUSIONS...... 158

9.1 High investment in reproduction...... 158

9.2 Population measures of women’s health...... 159

9.3 Risk factors for poor health outcomes...... 161

9.4 Health outcomes: Is there a relationship between maternal health and reproduction?...... 166

9.5 How do women buffer health?...... 169

9.6 Factors that restrict women’s abilities to buffer their health...... 173

9.7 Study limitations...... 175

9.8 Significance of results...... 177

BIBLIOGRAPHY...... 187

APPENDIX A IRB approval...... 208

xiii APPENDIX B Household and life history survey ...... 210

APPENDIX C Reproductive history questionaire...... 216

APPENDIX D Monthly interview questionaire...... 220

APPENDIX E Maternal mortality survey...... 226

xiv LIST OF TABLES

Page

Table 4.1 Participants in the study of maternal health...... 57 Table 4.2 Continuous variables used in the analyses...... 67 Table 4.3 Summary statistics for continuous variables used in the analyses...... 68 Table 4.4 Categorical variables used in the analyses...... 69 Table 4.5 Summary statistics for categorical variables ...... 70 (excluding health indicators) used in the analyses

Table 4.6 Summary statistics for categorical health indicators...... 71

Table 6.1 Household demographic information...... 89

Table 6.2 Summary statistics for participants...... 92

Table 6.3 Age-specific and total fertility rates...... 94

Table 6.4 Parity progression ratios...... 95

Table 6.5 Total fertility rates and mean completed family size ...... 96 – national, department, local estimates

Table 6.6 Comparison of ASFRs for Miskito communities in 2005 and 1992...... 97

Table 6.7 Multiple linear regression model for fertility...... 105

Table 6.8 Infant and under-5 mortality rates ...... 107 – national, department, and village levels

Table 6.9 Pregnancies, birth outcomes, and morbidity ...... 112 reports during reproductive events

xv Table 7.1 Comparison of stature across four populations...... 115

Table 7.2 Sample height, weight, and body mass index ...... 116

Table 7.3 Sample weight classification by BMI group for...... 116 non-pregnant women

Table 7.4 Prevalence of class 1, 2, and 3 obesity among ...... 116 non-pregnant women in the sample

Table 7.5 Linear regression model for BMI, non-pregnant women...... 118

Table 7.6 Circumference and skinfold measurements ...... 119 for non-pregnant women

Table 7.7 Multiple linear regression for arm circumference, ...... 120 non-pregnant women

Table 7.8 Multiple linear regression for waist circumference, ...... 121 non-pregnant women

Table 7.9 Multiple linear regression for mid-calf circumference, ...... 121 non-pregnant women

Table 7.10 Multiple linear regression for sum of skinfolds, non-pregnant women...... 122

Table 7.11 Description of the sample for hemoglobin...... 126

Table 7.12 Prevalence of mild, moderate, severe and total anemia...... 127

Table 7.13 Mean hemoglobin and anemia prevalence by age, ...... 127 reproductive status and parity

Table 7.14 Mean hemoglobin and anemia prevalence by socioeconomic ...... 128 status, education, BMI, family planning, and meat consumption

Table 7.15 Multilinear regression model for hemoglobin concentration ...... 129 by age, reproductive e status, and parity

Table 7.16 Multilinear regression model for hemoglobin ...... 130 concentration by reproductive status, BMI, SES, family planning, community of residence, meat consumption

xvi Table 7.17 Systolic and diastolic blood pressure levels...... 134

Table 7.18 Classifications of systolic blood pressure...... 135

Table 7.19 Classifications of diastolic blood pressure...... 135

Table 7.20 Comparison of women’s mean blood pressure ...... 135 in different populations

Table 7.21 Multiple linear regression model for systolic blood pressure...... 137

Table 7.22 Multiple linear regression model for diastolic blood pressure...... 137

Table 9.1 Results of studies that examined the relationship between ...... 168 parity and maternal condition

xvii LIST OF FIGURES

Page

Figure 2.1 Map of Honduras...... 11

Figure 2.2 Communities along the Ibans lagoon...... 11

Figure 2.3 The beach off of the village of Raista...... 20

Figure 2.4 Ibans lagoon...... 20

Figure 2.5 Boat bringing supplies...... 22

Figure 2.6 Line of people to help carry supplies...... 22

Figure 2.7 Map of villages along the Ibans lagoon...... 29

Figure 2.8 Map of the department of Gracias a Dios...... 32

Figure 4.1 Factors influencing reproduction and maternal health...... 73

Figure 6.1 Primary household wage earning activity...... 90

Figure 6.2 Age specific fertility rates...... 94

Figure 6.3 Parity progression ratios...... 95

Figure 6.4 The relationship between age and parity...... 105

Figure 6.5 Reports of morbidity during pregnancy...... 109

Figure 6.6 Reports of morbidity during childbirth...... 110

Figure 6.7 Reports of postpartum morbidity...... 111

Figure 7.1 Scatterplot of BMI and parity for women age 35-39...... 123 xviii Figure 7.2 Scatterplot of BMI and parity for women age 50 and older...... 123

Figure 7.3 Scatterplot of age and systolic blood pressure...... 138

Figure 7.4 Scatterplot of age and diastolic blood pressure...... 138

Figure 8.1 Reported causes of maternal death...... 142

Figure 8.2 Maternal deaths by age cohorts...... 143

Figure 8.3 Maternal deaths by the number of previous live births...... 144

xix CHAPTER 1

INTRODUCTION

1.1 Statement of the problem This study examines maternal morbidity and mortality in coastal Miskito communities where women produce many children, in the context of widespread poverty and inadequate access to healthcare. Data regarding current health status were also collected to analyze relationships among health indicators and reproductive, biodemographic, and socioeconomic factors. Using a biocultural approach to study women’s health in a high-risk local environment is necessary to identify variation in health, factors that increase women’s vulnerability to negative outcomes, and strategies they use to promote health despite difficult circumstances. Resource-deprived communities like those included in this research experience a disproportionate amount of the global burden of maternal morbidity and mortality. Despite international efforts like the World Health Organization’s (WHO) Safe

Motherhood Initiative which commenced in 1987 or the more recent United Nations’ Millennium Development Goals, over 500,000 women continue to die each year during pregnancy and childbirth (WHO 2004). While maternal mortality estimates focus on the worst case scenario - deaths due to complications of pregnancy/childbirth or a preexisting condition aggravated by pregnancy - many more women suffer from disease, malnutrition, and pregnancy-related illness and injury/disability. Studies (typically based on recall data) have estimated that for each death approximately 100 women also suffer

from debilitating conditions (Koblinsky 1995). Although mortality and morbidity are largely preventable, the use of effective interventions and availability of adequate and appropriate healthcare remain limited for vulnerable populations. Likewise, a major question remains as to how high fertility influences short-term and long-term maternal health in different local contexts. In the developing world, complications associated with pregnancy and birth are a leading cause of mortality and morbidity among reproductive age women (Ashford 2002). Roughly 99% of maternal deaths occur in developing countries (WHO 2004). The lifetime risk of maternal death for developing regions is 1 in 61 compared to 1 in 2,800 in developed areas (WHO 2004). Disparities between developed and developing countries are evidenced by multiple human development indicators; however, differences in maternal mortality rates are particularly pronounced (Rosenfield et al. 2007). In addition to widespread social inequality and inadequate access to resources that both men and women in developing countries experience, gender inequality plays a large role in perpetuating negative health outcomes among women. Within the household, women’s health may not receive priority status, particularly in families with limited resources (Das Gupta 1995). When women lack decision-making power, their access to material (e.g., adequate nutrition, health care) and non-material resources (education, self-esteem) may also be limited. Unequal division of labor and responsibilities based on culturally-defined gender roles can lead to high workloads and psychosocial stress when the burden of ensuring household survival falls mostly (if not solely) on them (Avotri and Walters 1999). Violence against women is also a substantial risk to women’s health throughout their life course (Watts and Zimmerman 2002). Trauma resulting from physical abuse may result in complications and negative birth outcomes among pregnant women in particular (e.g., placental abruption). Complications directly resulting from pregnancy and childbirth include severe bleeding (hemorrhage), infection (sepsis) during or after labor, prolonged labor or obstructed labor, pregnancy-induced hypertension, and unsafe abortion. Indirectly, diseases including anemia, malaria, cardiac disease, hepatitis, tuberculosis, diabetes, and sexually transmitted infections (such as HIV/AIDS) can be aggravated by pregnancy. In developing countries, direct obstetric complications cause most maternal deaths (McCarthy and Maine 1992). Unfortunately, these direct and indirect causes can also interact with each other, further complicating and exacerbating health problems (McCarthy and Maine 1992). Approximately 13 million women experience postpartum hemorrhage (the loss of over 500 milliliters of blood) each year (Ashford 2002). Hemorrhage represents the leading cause of maternal mortality. Severe bleeding is extremely dangerous, sometimes resulting in death within a few hours (Ashford 2002). Survivors may develop anemia (low concentration of hemoglobin in the blood) and in some cases tissue death in the pituitary gland (Sheehan’s sydrome) (Koblinsky 1995). In the case of pituitary failure, hormonal imbalances can occur and women may be unable to produce breastmilk, experience amenorrhea, and suffer chronic weakness/ fatigue (Ashford 2002). Anemia is much more common and may either be caused by a pregnancy complication (like hemorrhage) or aggravated by a complication.

Preexisting anemia is often a consequence of insufficient iron or folate in the diet and/or infection (malaria, HIV/AIDS, hookworm) (Koblinsky 1995). Anemia is associated with death and disability in mothers and low birth weight and stillbirth in offspring; even in moderate cases the resulting fatigue can impact productivity and quality of life (Koblinsky 1995). Sepsis is another prevalent complication that can lead to maternal mortality and morbidity. Infections during or after birth can result when labor/delivery or abortion occurs under unsanitary conditions. If a woman survives she still may develop pelvic inflammatory disease (PID). PID may damage fallopian tubes and ovaries, thereby increasing risks for ectopic pregnancy and infertility (Ashford 2002). Sepsis and hemorrhage may occur during obstructed labor as a mother struggles through a prolonged delivery. When the fetus cannot pass through a woman’s pelvic outlet both mother and child are at risk of dying, particularly when a Caesarean section delivery is not possible. Obstructed labor occurs primarily among very young or small women (the comparably large fetus cannot pass through the small pelvic outlet). Women who survive may suffer loss of their child as well as chronic incontinence, a ruptured uterus, or fistula. Repeated stretching and damage to the muscles that support the vagina and uterus can lead to genital prolapse (i.e., prevalence increases with parity) (Koblinsky 1995). Prolapse can result in chronic backache, urinary problems, pain during sexual intercourse, and future reproductive complications. Women also face the risk of hypertensive disorders induced by pregnancy including preeclampsia (defined by high blood pressure, swelling, and protein in the urine) and eclampsia (characterized by seizures or convulsions). In cases where anticonvulsant drugs and expedited delivery are not an option, this condition can lead to maternal and infant death (Koblinsky 1995). Among survivors, chronic hypertension, kidney damage/failure, paralysis, blindness, and nervous system disorders can compromise long-term health (Ashford 2002; Koblinsky 1995). Unsafe abortion also puts women at risk of death, ectopic pregnancy, PID, hemorrhage, sepsis, reproductive tract infections, uterine perforation, anemia, and infertility (Koblinsky 1995). A woman’s health status both prior to and during pregnancy influences her risk of death or disability. Nutritional status, the presence of infections, parasitic diseases, or chronic conditions like diabetes and hypertension impact health outcome. Diseases and prior history of pregnancy complications may also overlap with a new obstetric condition to decrease a woman’s chance of survival. For instance, the presence of anemia can increase the likelihood of death if hemorrhage occurs (McCarthy and Maine 1992). Maternal mortality and morbidity is largely preventable given access to effective health care services. Blood transfusions, antibiotics, delivery options like Cesarean sections, and availability of contraceptives and safe abortion can improve health outcomes (McCarthy and Maine 1992). However, health care facilities tend to be limited in developing countries (in terms of their establishment and quality of care offered; there also may be few trained providers especially in rural areas) (Sundari 1994). When complications arise, there are a number of factors that prevent women from seeking or receiving adequate treatment (Sundari 1994). Physical distance from services can impede use, as can negative perceptions regarding the adequacy of care patients receive. Time delay in arrival to a health care facility, language barriers, and perceptions about discrimination (particularly in the case of indigenous women) may contribute to poor maternal health outcomes. In areas where resources are scarce, the financial burden of transportation and treatment perpetuates high levels of mortality and morbidity as well. In the case of complications due to abortion, women may avoid seeking care owing to shame or fear that they will face legal repercussions (in areas where abortion is illegal).

1.2 Miskito case study For countries with limited resources, like Honduras, combating maternal mortality and morbidity is a struggle, particularly in isolated, rural areas. Previous research indicated that during the 1990s both fertility and maternal mortality levels were high in remote villages located in the department of Gracias a Dios. In a 1990 country-wide study, the highest maternal mortality rates occurred in this department which includes the Mosquitia region of eastern Honduras, with 878 maternal deaths per 100,000 live births (Danel 1999). Dodds (1994; 1998a;1998b) estimated total fertility levels at over 8 births per woman and growth rates of 3.7-4.3% for communities in the Rio Platano Biosphere Reserve. Despite these indicators of risk, information concerning the health of women in theses villages was scarce. This study investigates maternal mortality and morbidity in coastal Miskito communities located along the Ibans lagoon (for a map, see Figure 2.1). Miskito communities are ideal sites for this type of research because they are characterized by limited access to health care and high fertility. Current efforts to improve maternal health have focused on trying to provide some prenatal care during pregnancy and family planning services at local health centers. Given inadequate financial commitments to women’s health at the national level and a lack of transportation infrastructure at the local level, health interventions have been insufficient and sporadic. Health centers lack supplies, laboratory testing, and emergency obstetric care. Despite social change and integration into the global economy, these resource-deprived communities continue to experience widespread poverty and poor health outcomes. In all populations, women’s health is important because of their biological roles and cultural responsibilities as primary caregivers. However, these roles also put their health at risk when cultural ideals regarding high fertility are coupled with inadequate access to quality health services (Arias-Valencia 2001). Consequences of maternal morbidity and mortality for families are particularly pronounced in the Miskito case, because women play fundamental roles in household well-being. While men frequently work as wage labors away from their families for weeks at a time, women are responsible for all domestic tasks including cleaning, food preparation, hauling water, and childcare. Many also engage in productive work, including baking goods for sale, running small stores, and providing agricultural labor.

1.3 Theoretical significance Biological anthropologists strive to understand human variation within the framework of evolutionary theory. The ambitious and necessary goal of understanding how genes, the environment, culture, and behavior interact to produce variation at the individual and population level in growth and development, fertility, and health requires diverse and holistic investigations. This study contributes to the understanding of biological, behavioral, and socioeconomic factors that influence maternal health outcomes in Honduran Miskito communities. Despite the evolutionary and social importance of producing offspring, reproduction entails costs for the mother’s health. These costs require diversion of energy from the soma to the developing child. Life history theory predicts that fitness benefits reaped from investments in reproduction can be countered with maternal health consequences that potentially threaten long-term survival (Hill and Hurtado 1996). This trade-off is investigated in Miskito communities in eastern Honduras. The primary research question asks whether producing many children takes a toll on women’s health in high-risk environments (i.e., regions with high fertility and mortality rates and inadequate access to resources, including healthcare). This study also identifies social, political, economic, and biodemographic factors that influence variation in maternal health. Factors contributing to maternal mortality and morbidity are best examined in high-risk environments (Arias-Valencia 2001; Ronsman et al. 2006). Biodemographic factors for the Miskito population have not been well described. They are, however, living a high-risk lifestyle suitable for identifying strategies that women and their families have developed to promote their mutual well-being. As women cope with high reproduction in stressful physical and socioeconomic environments they likely approach the limits of human adaptability (Baker 1984). Here, interactions among biology, culture, and poverty become most basic as women’s abilities to buffer health mean the difference between life and death. The results of this study focus on these interactions to identify factors that lead to both vulnerability and resilience to poor health outcomes in this population.

1.4 Applied significance From an applied perspective, high maternal morbidity and mortality rates are significant public health issues. Maternal death and disability hold far-reaching consequences for individuals, families, and communities. For example, maternal mortality deprives households of their primary childcare providers and domestic laborers. Orphans often become economic burdens for family members who adopt them. Maternal mortality and morbidity deprive families and communities of leadership, reduce household economic output, and drain finances. Maternal morbidity and poor nutritional status not only impact a woman’s physiology, but also her economic well-being and mental health. Injuries like fistulas, for example, may lead to abandonment by a spouse and social isolation (Ashford 2002). Debilitating illnesses and injuries impact women’s economic productivity, and therefore family income and material well-being. Maternal morbidity jeopardizes a woman’s ability to perform important unpaid labor such as domestic food production, food preparation and childcare. Anxiety related to unstable household finances may lead to psychosocial stress. In turn, this may further compromise pregnancy outcome as well as health (by influencing immune function, for example), well-being, and fertility (Pike 2001). Mothers with compromised health are less able to invest in the development and health of their children. By examining how social factors are associated with the health and well- being of women, this project identifies strategies for promoting public health. Efforts to reduce maternal morbidity and mortality will only be effective if they are integrated with the specific preferences, circumstances and constraints of individuals and communities. Culturally and environmentally appropriate ways to improve maternal health are necessary. Effective maternal health programs depend on developing culturally and environmentally appropriate strategies that work through existing social networks. Expanding healthcare access across marginalized sections of populations will require not only appropriate programs but appropriate and inexpensive transmission. Data provided here inform public health policy and demonstrate the need for maternal health initiatives in coastal Honduran Miskito communities. The results of this study also suggest effective ways to address socioeconomic issues impacting women along with their families and communities. The Safe Motherhood Initiative heightened international awareness of maternal health; however it falls short of reducing maternal mortality rates in resource-deprived communities (Rosenfield et al. 2007). Regardless of funding priorities for public health, there is an ongoing need to examine maternal health risks in vulnerable populations to identify specific local problems and context-dependent barriers to improvements in maternal health.

CHAPTER 2

CULTURAL CONTEXT: COASTAL MISKITO COMMUNITIES IN HONDURAS

2.1 Background information The Miskito, an indigenous Misumalpan-speaking population, live within the Mosquitia region of eastern Nicaragua and Honduras. In Honduras, the Miskito primarily live in the least populated (and least densely populated) department in Honduras (see Figure 2.1 for a map). According to the 2001 Census less than 57,000 people lived in the Department of Gracias a Dios, of which 83% identified themselves as Miskito (INE 2001). This research focuses on coastal communities located along the Ibans lagoon (Figure 2.2). The combined population of these communities included approximately 5,000 people during the period of this research. The Mosquito Coast is relatively isolated, with the primary means of transportation being canoe, airplane, or foot (Dodds 1994). Despite the region’s relative remoteness, cultural contact during the last three hundred years with buccaneers, missionaries, and entrepreneurs in search of wage laborers has influenced, if not created, Miskito society (Helms 1971, Nietschmann 1973; McSweeney 2004). The Miskito do not represent a pristine, untouched population, but they can be described as persistent and adaptable (Dodds 1994).

10 Figure 2.1 Map of Honduras

Figure 2.2 Communities along the Ibans lagoon *Photo by Steve Collins 11 The Miskito utilize a flexible subsistence system that allows them to practice both food production based on reciprocity among kinship groups and wage labor in the market economy (Nietschmann 1973; Helms 1971). The Miskito subsistence system includes fishing, some hunting, raising domesticated animals, and swidden agriculture (Dodds 1994). Crops, which typically include plantains, bananas, manioc, rice, beans, and maize are planted inland on the other side of the lagoon in fields cleared from both primary and secondary forest (Dodds 1994; Helms 1971, Nietschmann 1973). They also depend on trees in the villages for coconuts and other fruit. Traditionally, men clear agricultural fields, a task that requires heavy labor. Women harvest the root crops, keep food supplies stocked in the house, care for children and do domestic work (e.g., food preparation, laundry). Since European contact, the Miskito have participated in various market activities, including engaging in export industries as wage laborers and purchasing commercial products themselves. Local stores and traveling vendors sell clothes, tools, gasoline, and food items im Miskito communities.

2.2 Historical context In the mid-seventeenth century the Miskito population was estimated at less than 2,000 people in villages scattered along the Mosquito coast (Nietschmann 1973:

26-27). Unlike many indigenous groups in Latin America, the Miskito experienced an increase in both population and territory after European contact in the mid- seventeenth century (Dodds 1994). The Miskito population is now approximately 250,000 people residing in a territory the size of Costa Rica (Nietschmann 1997). In eastern Honduras, approximately 38,000 Miskito live in 141 settlements (Herlihy and Leake 1993; Dodds 1994). The Miskito people have employed different strategies to accomplish their population expansion and increased control over land and sea 12 resources. Interethnic mixing appears important as the groups that would come to identify themselves as Miskito readily incorporated outsiders (buccaneers, traders, and escaped African slaves) into their population and continue to do so (Dodds 1994). Offen (1999; 2002) emphasizes that mixing among indigenous coastal people, African slaves, and European pirates beginning in the 17th century created the ethnic groups (the Tawira and Sambo) that would come to be known as the Miskito, a general classification based on a common Misumalpan language. The term Misumalpan refers to a language stock that includes Miskito, the Sumu of Honduaras and Nicaragua, and Matagalpa-Cacaopera of El Salvador (Mason 1973). However, the Miskito grammar is simpler and incorporates many nouns borrowed from other languages, especially English (Helms 1971; Heath 1913). In terms of genetic ancestry, the Miskito people can be considered Amerindians with African and European admixture (Azofeifa et al. 1998). Guns provided by pirates and traders allowed the Miskito to raid other indigenous and Spanish settlements (often in alliance with the English), leading to a significant gain in territory along the coast of Honduras and Nicaragua (Helms 1983; Dennis and Olien 1984; Dodds 1994). This raiding marks a historical trend in Miskito life, where men leave their villages for prolonged periods of time (Helms 1971). Even today, men spend two or more weeks of the month away from their homes while they work at sea on lobster boats. Over time, Miskito involvement with other societies and economic systems led to increasing exchange of labor, resources, and goods. Early trade with Europeans involved the exchange of natural resources found in the region (dyewoods, animal skins, shell, turtle meat, sarsaparilla, rubber, indigo, and cacao) for foreign goods (clothes, machetes, rum, tools, muskets, gunpowder, cooking pots) (Helms 1971). The Miskito people’s increasing desire for these commercial goods encouraged 13 future involvement with foreign-owned companies that established business on the Miskito Coast, particularly in the nineteenth century. Resource extractions by foreigners depended on availability and market demand, making operations generally unstable and short-lived (Nietschmann 1973: 24). Participation in the global economy is therefore not a new development; the Miskito people have been involved in international trade for over 250 years (McSweeney 2004). Helms (1971: 27) argues that the economy produced in this environment of speculation, disease, overextraction, government instability, and conflict was “characterized by small booms and subsequent busts”. Lumbering operations, rubber collection, and banana plantations provided labor for the Miskito in these boom and bust cycles. This led to increased culture contact, more involvement with a cash- based economy, and the prolonged absence of men from villages (Nietschmann 1971: 40). As money became increasingly available and important, it threatened cultural practices of communal exchange labor and reciprocity. However, the Miskito did not become completely dependent on foreign cash or the market economy. The indigenous group continued to practice traditional subsistence methods based on kinship and reciprocal exchange which allowed them to deal with bust periods. These bust periods allowed a return to traditional cultural values/practices and therefore may have contributed to ethnic persistance (Helms 1971). The Miskito engaged in wage labor not for survival, but to supplement agriculture, fishing, and hunting activities. They earned cash in monetary economies to buy foreign products which came to be culturally perceived as necessities. Therefore, Helms labeled the Miskto as a “purchase” society because they lack some characteristics that define peasants (namely surplus extraction) (1971: 7).

14 2.3 Current subsistence/economy Miskito culture and subsistence in Honduran and Nicaraguan communities have received a high degree of ethnographic attention (see for example, Helms 1971; Nietschmann 1973; Dodds 1994; Dennis 2004; Herlihy 2002). Today, coastal Miskito households rely on subsistence products and cash to meet their needs. People practice agriculture for subsistence, but they also sell surplus crops and work in other families’ fields for wages. Other opportunities for earning money include working as teachers, nurses, doctors, pastors, and employment with non-governmental organizations. Doing laundry, selling baked goods, cooking for other individuals or families, and running boarding houses are less profitable, but they also represent important economic strategies, especially for women. Some families also rely on remittances from city-dwelling kin. Coastal communities like those included in this study are particularly dependent on the wages men earn working at sea on lobster, shrimp or other fishing boats. Families buy commercial goods with cash earned from wage labor or from selling surplus agricultural produce.

Wage labor Today, many men work as lobster divers in the international lobster economy (Dodds 1998c). The outcomes of a small-scale society participating in a global market system prove to be both positive and negative for the Miskito and their environment . In ecological terms, intensified harvesting overexploits lobster populations, with yields showing a significant decline since the industry began in the 1970s (Dodds 1994). However, evidence exists for a decrease in local deforestation at the same time (Dodds 1998c). Money earned from lobster work relieves some of the pressure to clear new fields for cash crops, thus offsetting some of the pressure on local forests. 15 At the social level, employment provides increased incomes to purchase desired store-bought products. Lobster diving can yield high wages; in fact, people refer to working on boats as “going to the bank” (“el banco”). The cash a diver can earn in two weeks approaches the income generated by a year of cash-crop production (Dodds 1998c). Divers typically receive at least $200-300 per trip (Dodds 1994; 1998c) and sometimes as much as $1,000, though success is highly variable. Miskito families use this cash to buy store-bought foods including flour, salt, sugar, vegetable shortening, coffee, rice, and beans. They also purchase commercial goods like clothing, matches, cooking utensils, school supplies, agricultural tools. These wages also finance health care (both traditional and Western medicine) and travel expenses (Dodds 1994; 1998c). However, divers often spend a large portion of their lobster income on beer, rum, cigarettes, and illegal drugs. They also occasionally buy luxury items such as audio cassette players, radios, and clothing for themselves (Herlihy 1997: 109; Herlihy 2002). There are few formal ways to save money in these communities, so cash from each diving trip is typically spent quickly. Lobster diving typically takes men away from their homes for about 25% of their time (Dodds 1994), with single excursions lasting two to three weeks. The lack of a consistent male work force affects domestic agricultural work (Dodds 1998c). Men are responsible for the heavy labor involved in clearing fields in preparation for planting. Members of the family plant crops, weed the fields, and then harvest food in upriver agricultural camps. When men leave to work in the lobster industry, women must rely on relatives or wage laborers (men who do not work on lobster boats) for help with production (Dodds 1998c). Otherwise, families’ agricultural production is limited to months of the year when men are not working at sea. Miskito culture and social arrangements appear to mitigate the strain that male absenteeism places on households. After all, this is not a new condition. 16 Nietschmann (1973) argues that women assume integral roles in the perpetuation of Miskito culture, kinship patterns, and traditional systems of food distribution. The coastal Miskito typically live in matrilocal residence groups, with mothers, daughters, and sisters creating and maintaining important social and economic networks (Nietschmann 1973; Herlihy 2002). The inheritance of land and sharing of food (including meat) and other resources occurs among members of the matrilineage (Herlihy 2002). Grandmothers, mothers, maternal aunts, older sisters, and female cousins share in childcare responsibilities (Herlihy 2002). Women work collectively to meet daily household needs, especially in the absence of men. The physical nature of the lobster work itself also affects the Miskito population, as men face potentially dangerous labor conditions. Men employed as divers use scuba equipment while they retrieve lobster without the use of traps. Many hazards stem from diving owing to a lack of training (men often dive to great depths for long periods of time and resurface quickly) and contaminated tank air. Decompression sickness often results in impotence, impaired brain function, paralysis and death. In addition, divers may cross paths with drug traffickers transporting cocaine from Colombia to the US. Drug cartels launder money through the lobster industry and often provision divers with cocaine (Nietschmann 1997). Also, sun, wind, exposure, strong underwater currents, and marine predators (sharks and barracudas) add to the dangers faced by divers (Dodds 1994). Lobster diving represents a source of stress for men’s family members as they worry about whether their fathers, sons, and spouses will return home safely or end up paralyzed, dead, or stranded at sea during storms. Even with increased international attention, this labor safety problem has yet to be resolved (Dodds 1998), although some attempts to address the risks men face have been made. Retired (and often injured) divers have created an organization for divers to raise awareness and improve conditions. 17 Presently, men have to undergo a physical at a local health center before they can find employment on a boat. Yet, inhumane working conditions and ecological deterioration due to lobster harvesting continue to pose threats to Miskito welfare. Although there are a number of jobs available on fishing boats (e.g., packing the fish, shrimp, lobster, cooking for the crew, navigating canoes for individual divers), divers earn the highest economic returns for their labor. Women can also generate income; however, their opportunities as wage laborers are limited compared to men. Occupations are clearly segregated by gender (Herlihy 2002). Women tend to be more susceptible to poverty than men in these coastal communities because they lack employment opportunities, and therefore, economic autonomy. Although they may be able to find work washing clothes, cooking, or selling baked goods these jobs tend to be low paid and temporary (though the exceptions would be jobs in nursing and teaching). Alone, women’s income cannot sufficiently provide food and other resources for their children, so women with young children in particular typically rely on wages men earn working at sea to meet household needs. This economic dependence on men is problematic for women when their spouses choose to spend the money they earn on alcohol, drugs, luxury items for themselves, or other women. During interviews, women often reported stressful conflicts with their spouses over the irresponsible spending of money. These fights can become violent at times, particularly when drugs and alcohol are involved (personal observation). The lack of employment opportunities outside of working at sea presents difficulties for household economies because for at least four months out of the year a government-imposed moratorium (or veda) on the extraction of marine resources leaves men without jobs and families without the money needed for food, health care, transportation and other necessities. The four month moratorium represents 18 a national effort to conserve sea resources and prevent overexploitation of lobster, conch, shrimp, and fish. However, the lack of cash flow in coastal communities causes local economies to almost shut down during the moratorium. Everyone (not just households that depend on lobster diving) feels the effects of the economic downturn. Small shops are less well-stocked as less business means that owners cannot afford new products. People stop running collective transportation services as most people cannot afford to use them. Without the movement of money that working at sea provides, agricultural laborers also have fewer wage earning opportunities. Although subject to change, the moratorium usually begins on April 1 and lasts through the month of July. During the moratorium, many families concentrate on agriculture and spend more of their time on the other side of the lagoon working in inland fields. People plant rice during the moratorium as well as manioc, bananas, and plantains (which can be planted and harvested year around). While some families basically live inland during the moratorium, women with school-aged children often remain in coastal villages so children can continue to attend school. Despite the fact that most families engage in some agricultural work, few grow enough food to support household needs throughout the year (see Herlihy 2002).

Agriculture

Diversity characterizes the Mosquitia region, which includes offshore coral reefs, lowland coastal savannas, and inland riverine areas surrounded by tropical forests (see Figures 2.3 and 2.4). The humid tropical climate is typically divided into two seasons, wet and dry (see Dodds 1994). Most rainfall occurs from June through August and the least, from January through May. However, precipitation varies greatly from month-to-month (or even week-to-week) during these seasons. As the drier season comes to an end, mean temperatures are typically highest for the months of April and 19 May, though high temperatures may reach or exceed 40 degrees Celsius at almost any time of the year (Dodds 1994). Hurricane season typically extends from August to October; however, in the year 2005 (a particularly active hurricane season) storms continued into November and caused wind damage and major flooding in the region.

Figure 2.3 The beach off of the village of Raista

Figure 2.4 Ibans lagoon

20 Households typically clear fields during the dry season, and the moratorium makes men’s labor more available during the months of April and May in particular. Families plant rice in May, before the rains come in June, and then harvest it in September or October. Although plantains, bananas, sweet manioc, and malanga (Malanga amarilla) can be planted at any time during the year and harvested about 9 months to a year later, people prefer to plant them during the dry season by March or April when possible. There are some exceptions to the focus on agriculture at the end of the dry season with harvests during the wet season. People plant beans in December or January and harvest them in February or March. Also, families prefer to plant watermelons during the dry season. Trees, including coconut, cashew, mango, papaya, orange, lime, avocado, breadfruit, and nance (Byrsonima crassifolia) provide fruit seasonally. Various types of fruit ripen at different times of the year, mostly during the wet season and into September and October.

Diet and nutrition Families in these coastal communities buy most of their food from small local stores which import food on supply boats from the city of La Ceiba (see Figures 2.5 and 2.6). Stores typically sell coffee, sugar, beans, rice, pasta (spaghetti noodles), flour, salt and some condiments and seasonings (e.g., onions, garlic, tomato paste). Prices of food

items are sometimes twice as high as the same goods sold in cities because of the cost of transportation. Also, during times of bad weather boats cannot travel to the Mosquito Coast, thereby preventing store owners from replenishing supplies for weeks. Less frequently, supplies are brought by pick-up trucks that drive along the beach to reach coastal communities. Some households also buy bread and other baked goods (usually children sell items door-to-door), fish, or meat if someone in the local community slaughters a cow or pig in the village. However, in general, women have few nutritious food options. 21 Figure 2.5 Boat bringing supplies

Figure 2.6 Line of people to help carry supplies

Meals usually consist of rice, a starchy tuber (e.g., manioc) or starchy fruit (e.g., plantains, bananas), and if possible, some protein in the form of meat, fish, or beans. Diets are high in sugar and vegetable shortening, but low in fresh vegetables. Fresh, ripe fruits are typically considered children’s food, but adults occasionally eat mangoes, oranges, papaya, and other fruits as well. Although many women grow fruit

22 trees, they do not practice the labor-intensive gardening strategies necessary to grow vegetables on the coast. A vendor who imports vegetables from La Ceiba travels to these communities sporadically with produce; however, high prices preclude most households from buying anything. Women typically eat three meals each day. Breakfast includes coffee and bread/tortillas or leftovers from the previous evening’s dinner. Lunch is the largest meal of the day and consists of a boiled starchy vegetable or fruit (e.g., bananas, plantains, manioc), white rice, and protein (e.g, red beans, fish, meat). Dinner includes a smaller meal of starch and protein, often rice and beans or fried plantains/ bananas and fish/leftover meat. Women may also consume snacks (mangos, papaya, oranges) during the day and coffee in the evening or afternoon. Meat, beans, and starchy fruits and vegetables are typically boiled (often in soup) or fried. Food is often prepared with vegetable shortening (whether boiled or fried) and women drink each cup of coffee with one to two spoonfuls of sugar. Wealthier women can afford to buy bread from local bakers, meat and cheese from local sellers, and more coffee and sugar from local stores on a regular basis, while poor women’s options are more often limited by economic constraints. Vendors from La Ceiba periodically come to the coast to sell medicine, second-hand clothes, shampoo, and tools. Some of the larger local stores also sell non-food items. Families must also purchase uniforms and books for children who attend school. Earning the money to feed, clothe, educate, and provide adequate shelter for a family given the socioeconomic context of limited job opportunities and growing needs for cash (as both purchases and prices rise). Community members cite increasing costs of education, health care, food, gasoline and other commercial goods as barriers to raising large healthy families.

23 2.4 Residence patterns The culturally ideal pattern of residence in coastal Miskito communities is for new couples to establish a household next to the woman’s mother and sisters (or share the home of the woman’s family until they can afford to build their own house). However, the degree of matrilocality appears flexible and varies among villages and individual families (Herlihy 2002; Dodds 1994). Matrilocal residence groups serve as important economic units, with regard to decision-making and production. As men are typically absent during wage labor activities, women work together to meet daily household needs. At certain times of the year, coastal matrigroups (including women, children, and men who are not working as lobster divers) travel inland to family agricultural camps to collectively engage in labor-intensive subsistence activities (Herlihy 2002). The inheritance of land and sharing of food (including meat) and other resources occurs among members of the matrilineage, but children are given their father’s surname (Herlihy 2002). The exchange/adoption of children typically occurs between female relatives, especially when a woman has no female children of her own (Herlihy 2002). Matrilocal residence groups appear to be particularly important in the case of childcare, as they function like an extended household where grandmothers, mothers, maternal aunts, older sisters, and female cousins share in childcare responsibilities, including nursing (Herlihy 2002). Cousins in the matrilineage are treated (including kinship terminology) as siblings. Women collaborate to diagnose and treat children’s illnesses and daughters receive instruction on how to use plants to cure health problems (Herlihy 2002). The matrigroups of the Miskito may prove beneficial not only in the context of male absenteeism, but also under high maternal mortality conditions. Female relatives living in close proximity to households that suffer the loss of a mother may contribute essential support and labor to the family or adopt 24 children if the new widower decides to leave the village. In families that reported maternal deaths, maternal grandmothers were most likely to adopt orphaned children.

2.5 Population dynamics A variety of ethnic groups (e.g., the Miskito, Tawahka, Pech, Garifuna) inhabit the Mosquitia and contribute to its diverse cultural landscape. Even within the Miskito villages included in this study, community members included non- indigenous (ladino) families and individuals who identified themselves as Pech, Garifuna or other ethnicities, albeit in low frequencies. Although population density in the department of Gracias a Dios is low, demographic change characterizes the region. Dodds (1998) estimates total fertility rates of over 8 births per woman, an infant mortality rate of 40 per 1,000 live births, and growth rates of 3.7-4.3% for Miskito communities in the Rio Plátano Biosphere Reserve (see figure 2.1 for location of reserve). Today, the Miskito struggle over rights to control and manage their traditional land. Environmental degradation due to deforestation and overexploitation of marine resources by outsiders (e.g., non-indigenous entreprenuers) for export industries potentially threaten the Miskito’s ability to support their growing population. Dodds’ (1994) also argues that Miskito population pressure will also jeopardize the sustainability of the local subsistence system. His analysis has led him to conclude that although the current subsistence system may be capable of providing adequate nutrition for members now (based on weight-for-height measures), the growing population will eventually outstrip the environment’s resources. For example, 37% of each year’s cropland used for swidden agriculture is cleared from primary forest (Dodds 1994). Dodds’ (1994) model predicts that the community of Belen (Northern coast of Rio Plátano Biosphere Reserve) in Honduras will run out of land in only 60 years. This issue may also be exacerbated by the increasing migration 25 of non-indigenous people (campesinos) searching for land into traditional Miskito territory (Herlihy 1997). However, emigration by Miskito people could also mitigate population pressure in the region. The Honduran government has established various reserves and protected areas in the country, including the Rio Plátano Biosphere Reserve in 1980. The reserve consists of 500,000 hectares (350,000 hectares make up the reserve, with another 150,000 hectares classified as buffer zone) (Dodds 1994). About 6,000 people live in the reserve, and most of them are Miskito (Dodds 1994; Herlihy 1997). However, government officials usually pay little attention to the needs and rights of indigenous peoples and direct few resources to management and protection of the reserve (Herlihy 1997). Although they typically hold no legal land title (Herlihy 2002), the Miskito recognize land ownership through kin lines as well as usufructuary rights to agriculture lands (Herlihy 1997). They share communal hunting, fishing, and foraging territories. In light of recent demographic trends, resource security will likely remain an important issue. However, the Miskito people have successfully dealt with challenging conditions for hundreds of years. Their abilities to cope with discrimination and difficult circumstances have led to impressive mobilization and political gain (Hale 1994). They have adapted to European contact (Helms 1971; Nietschmann 1973) and transformed colonial institutions (e.g., the Miskito Kingdom established by the British, Christianity introduced by missionaries) to work toward their own goals and within their unique belief system (Dennis and Olien 1984; Dennis 2004). Although poor and vulnerable in some respects, the Miskito are also highly capable and resilient.

2.6 Previous research regarding health While fertility rates are high, Miskito women express desires for smaller families (on average prefering two fewer children than the actual mean completed 26 family size) (Dodds 1994; 1998), creating a discrepancy between the reported ideal and the real situation. Increasing costs of children, education, health care, and commercial goods may be responsible for changing perceptions of desired family size (Dodds 1994;1998). Given a changing physical and socioeconomic environment, some women view families with fewer children as able to allocate more resources to each one, thereby better ensuring the survival and success of individual offspring. However, smaller families may be precluded by cultural and individual perceptions of the value of children, mortality risk, and the need to ensure Miskito persistence and prosperity through population growth (McSweeney and Arps 2005). High fertility among other indigenous populations has been linked to achieving political and economic goals associated with demographic resurgence (Azevedo 2000; Martins Pereira et al. 2002). High fertility can have negative consequences for maternal and child health particularly when individuals lack resources and social support (Alam 1995; Bohler and Bergstrom 1995; Tracer 1991). High fertility appears to be coupled with high maternal mortality in this region. In 1990, the highest maternal mortality rates in the country occurred in the department of Gracias a Dios in the Mosquitia region of eastern Honduras, with 878 maternal deaths per 100,000 live births (Danel 1999). In the Mosquitia, maternal mortality accounted for 46% of deaths to women of reproductive age (see also Dodds 1994). The leading causes of death included infection, hemorrhage, and hypertensive complications. The lack of health care available to women in the Mosquitia perpetuates the problem. Women play integral roles in production, maintaining the household, and childcare. Thus, maternal death decreases child survival and household well-being. In terms of child survival, Dodds (1998) found that infant mortality rates roughly parallel the national rate. Dodds (1994) analyzed weight for height and height for age among 123 school children ages four to sixteen. The children were within 27 normal ranges (based on National Center for Health Statistics Reference Data) for weight for height. However, Miskito children were small when it came to height for age. This may indicate long term nutritional deficits as 46.3% were stunted. He speculates that a diet consisting of low calorie-density foods and/or high disease loads may be responsible for growth stunting. Similar patterns have been reported for some Amazonian populations (Silva and Crews 2006). In circumstances where women suffer from gender inequality and poverty, reproduction is expected to be most costly. Within communities, differences in socioeconomic status exist among Miskito households and may become more pronounced through time. Many men work as divers for the lobster industry and earn wages that contribute to household income (Dodds 1994; 1998). Involvement in professional occupations (e.g., teaching, nursing) or the ecotourism industry may bring higher economic returns to certain families as well. Herlihy (2002) points out that households in the region do not equally share in the economic benefits of market integration. Income levels impact families’ abilities to afford health care expenses, namely the cost of transportation to clinics and hospitals.

2.7 Communities along the Ibans lagoon To reach communities along the Ibans lagoon, travelers must take a plane or truck along the beach followed by a canoe ride. Not only is transportation infrastructure in the department of Gracias a Dios limited, the general infrastructure in these remote communities is also restricted. Many households lack access to an improved source of water (i.e., a safer, uncontaminated source of drinking water) and families must send children to cities if they choose to attend high school. However, development efforts have brought more resources to these communities, including bilingual education programs and efforts to expand access to potable water. 28 Just two villages along the Ibans lagoon (Cocobila and Belen, see Figure 2.7) currently have systems to deliver improved water to households. Families with water faucets near their homes pay fees to finance the cost of gasoline to pump water from underground aquifers. Water typically runs for ten to fifteen minutes at a time, when community members can collect enough money to fuel the system (maybe as often as once a day to as infrequently as once a week). Families collect water in buckets to use for cooking, drinking, cleaning, and laundry. Many households in the village of Ibans have small hand pumps in their yards which give them constant, albeit slow, access to water thanks to a past development project that constructed and funded the pumps for families that desired them. Other households depend on wells, larger water pumps, or the lagoon to meet their needs for water. During the investigation, members of communities along the Ibans lagoon were in the process of constructing a large water system (partly funded by the European Union) that would serve almost all of the villages included in this study. Though the system was planned to be up and running by April 2004, as of November 2005, it remained non-functional.

Figure 2.7 Map of villages along the Ibans lagoon 29 Children have access to primary schools (kindergarten though sixth grade) within walking distance, and most communities have their own schools. Classes are taught in both Miskito and Spanish in the early years until students become more fluent in Spanish. The number of middle schools is also growing in the region, though most villages share facilities. Non-traditional students (i.e, older people who did not attend or finish school earlier in life) may enroll in continuing education classes. The program welcomes both men and women, but the majority of participants are women who dropped out of school for a variety of reasons, including marriage and childbearing. Churches of different Christian denominations hold services and serve important social functions in coastal villages. The Moravian church has historically exerted the most influence in Miskito communities (Helms 1971; Nietschmann 1973; Dodds 1994). In fact, most communities along the Ibans lagoon have both a traditional Moravian church as well as a reformed Moravian church. Pastors and senior leaders in the church counsel parishioners, facilitate marriage arrangements, hold vigils for sick church members, and represent a political force when it comes to community issues (personal observations and reports from community members). For instance, churches work to prohibit the sale of alcohol in certain areas or villages. Although malaria is endemic in the region, there are fewer mosquitoes in the coastal communities than in inland areas, where there is more standing, fresh water. People often state that the lack of mosquitoes on the coast makes living in these communities more attractive. Mosquito populations do increase periodically, especially after precipitation or in the wet season, though they remain highly variable, so pinpointing the months when risk of malarial infection is highest remains difficult. The lack of testing services at local health centers to identify malarial infections among people in the village also complicates generalizations about seasonal disease loads. 30 Two health care centers are located in coastal communities along the Ibans lagoon. Both employ a doctor (one male, one female doctor) and multiple nurses. People pay a consultation fee for services (5-10 Lempiras depending on their time of arrival; US $0.30-0.60). Diagnostic and treatment services are limited as both lack laboratory testing facilities and pharmacies are poorly stocked. Doctors often send people to private pharmacies to purchase vitamins or medicine when out-of-stock at the health center. However, prices are higher and supplies at private pharmacies are also limited. There are only three major private pharmacies shared by the villages along the Ibans lagoon, but many general stores also sell pain relievers like acetaminophen. Health centers do offer free prenatal care for pregnant women and vaccines for children. Nurses at the health centers enoourage women to come for a prenatal visit each month to screen them for complications, check the size and position of the fetus, and ideally provide them with a month’s supply of prenatal vitamins. Yet, health center doctors or nurses rarely attend births. Instead, women typically give birth at home with help from local midwives and/or private nurses. Midwives are women with experience attending births and varying degrees of biomedical training. Multiple midwives reside in each community and provide some prenatal care (e.g., check size and position of fetus, offer advice to pregnant women with health complaints) in addition to attending births. While midwives earn whatever a family can afford to pay them for their services, private nurses often charge more to attend births or provide other health consultations. In the study communities, three women with nursing training have each established large healthcare practices. They often offer medicine and other treatment options (like injections of pitocin to induce labor) that remain unavailable with midwives or at the health center. Other biomedical services are available if individuals possess the resources to travel longer distances for healthcare. In Palacios, a community that requires about a 31 two hour trip in a motorized canoe, there is a private health clinic with a doctor who can perform some minor emergency surgeries. The best options, in terms of range of services available, include the private hospital in Ahuas or the public hospital in Puerto Lempira. However, traveling to Ahuas or Puerto Lempira requires expensive transportation by motorized canoe (an all day trip) or by a chartered plane (Figure 2.8). People often seek non-biomedical healthcare in these villages as well. Some types of ‘Miskito medicine’ are well-known and widely shared among friends and family members, but for many ailments community members seek help from traditional herbalists (curanderos). Local healers can be found in each community. Some midwives also know and use herbal treatments to help labor progress and stop severe bleeding. People often seek different types of treatment – both traditional and biomedical – to solve or prevent health problems. Private nurses and midwives may practice beside traditional herbalists in these communities.

Figure 2.8 Map of the department of Gracias a Dios

32 CHAPTER 3

THEORETICAL BACKGROUND AND CONCEPTUAL TOOLS

3.1 Primary research goals and questions Biological, behavioral, and socioeconomic factors influence maternal health outcomes everywhere (WHO 2004). Environments with widespread disease and poverty are significant stressors for populations, specifically women.As an ethnic minority marginalized historically and presently by the national government, the Miskito people lack both economic and political security (Nietschmann 1997). Indigenous women experience a double burden, because gender inequality blocks their access to resources (Gomez 2004). This research project identifies and explores reasons for both population and individual variation in fertility and maternal health. Because both fertility and maternal morbidity and mortality are high, interactions between reproductive measures and maternal health status are highlighted. Trade- offs between investing in reproduction and maintaining maternal well-being occur because investments in reproductive effort reduce resources available for promoting health and long-term survival. Trade-offs are likely harsher when communities and individuals lack access to adequate resources. This research identifies the costs of reproduction on maternal health and how these costs vary among individuals. It also examines which biodemographic and socioeconomic factors place women at risk of poor outcomes. Last, it considers how women in this particular setting buffer their health from the potential costs of reproduction. The next section of this

33 chapter lists the primary research questions and hypotheses examined. Hypotheses are broad and based on relationships well-predicted elsewhere. However, given the lack of information regarding maternal health in this context, such an approach is necessary to identify specific factors that affect maternal well-being in these Miskito communities. Evolutionary and life history perspectives providing the theoretical basis for conceptualizing this research are detailed in the remaining sections.

Primary research statements and hypotheses:

1. Biodemographic and socioeconomic factors explain fertility variation among Miskito women.

Hypotheses: Older age (more years to reproduce), younger age at first reproduction (reproduction begins earlier thereby lengthening the reproductive span), earlier ages at menarche and marriage (influence how early women begin reproducing), socioeconomic status, lower education level, less contraceptive use, shorter durations of breastfeeding, less autonomy in decision-making, larger ideal family size preferences are positively and significantly associated with indicators of fertility (e.g., gravidity, parity).

2. Investment in reproduction compromises women’s health.

Hypotheses: Higher gravidity, higher parity, shorter birth intervals, higher rates of morbidity during past reproductive events, and current pregnancy and lactation (e.g., women presently experiencing the demands of reproduction) are negatively associated with health. Health indicators analyzed include

34 body composition (body mass index, skinfolds, body fat reserves), systolic and diastolic blood pressure, and hemoglobin concentration.

3. Biological, demographic, and socioeconomic factors influence women’s health.

Hypotheses: Low socioeconomic status, large households, young households (age composition), low education levels, the lack of contraceptive use, less social support, living in communities with fewer resources, less autonomy in decision-making, dietary intakes of poor quantity and quality (controlling for other socioeconomic variables), and less use of health care are negatively associated with health. Again, the health indicators analyzed include body composition (body mass index, skinfolds, body fat reserves), systolic and diastolic blood pressure, and hemoglobin concentration.

3.2 An evolutionary perspective on reproduction: Maternal health and fitness

Natural selection has acted on the process of reproduction in living organisms for 500 million years, primates for 60 million years, hominins for 6-7 million years, and humans for approximately 200,000 years. Still, pregnancy and childbirth are risky for women. Risks vary across populations and individuals, but may lead to death, disease, or disability (McCarthy and Maine 1992). Reproductive events, particularly pregnancy and birth are defining moments for natural selection. Depending on environmental conditions during pregnancy and birth, women, fetuses, and newborns may face both short-term

35 health and survival risks and longer-term consequences for well-being and lifetime reproductive success (Pike 2001). A woman’s lifetime fitness is measured in terms of reproductive success (the number of offspring produced that survive to reproductive age) or her genetic contribution to subsequent generations relative to other individuals in the population. Therefore, the sum total of women’s experiences during their reproductive years influence the number and outcome of reproductive events that contribute to lifetime reproductive success (Peacock 1991).

Maternal morbidity and mortality potentially influence both present and future reproductive events, and therefore, a woman’s lifetime fitness. Maternal death is accompanied by a high risk of poor birth outcome, particularly fetal/infant death (Koblinsky 1995). It not only terminates a woman’s opportunity to produce future offspring, but also ends her ability to invest in and ensure the survival of living children. Death during the period of offspring production and fledging compromises a woman’s lifetime reproductive success. Fitness may be negatively affected by maternal death depending on the number of offspring the woman produced. If she had fewer children than other women in the population, her genetic contribution to future generations will be relatively lower.

Maternal morbidity during pregnancy, birth, or the postpartum period can have acute or chronic effects on health. Depending on duration and severity of the complication, morbidity can impact birth outcome and a woman’s ability to invest in current children as well as her future fecundity and fertility. Maternal nutritional and health status influence pregnancy outcome. Complications during pregnancy and birth, management of delivery, and poor maternal health and nutritional status are associated with at least 75% of perinatal deaths (Koblinsky 1995). Leading causes of death include prematurity, low birth weight, asphyxia, infections, congenital malformations, and birth

36 injuries (Koblinsky 1995). Intra-uterine growth retardation and/or premature birth can lead to low birth weight. In the case of preterm births, low birth weight is associated with higher mortality rates owing to conditions that increase infants’ chances of death, including immaturity of their lungs (Koblinsky 1995). Intra-uterine growth restriction influences short and long-term morbidity and mortality risk, patterns of growth and development, and later reproductive function (Pike 2001). Women with compromised nutritional status prior to pregnancy, during pregnancy (including inadequate weight gain and anemia), or who experience infection during pregnancy are at increased risk of having low birth weight infants (Koblinsky 1995). Not only do maternal morbidity/mortality influence lifetime reproductive success, but reproductive events (independently and/or collectively) also increase opportunities for death and disability. Each pregnancy exposes women to the risk of maternal morbidity/ mortality (McCarthy and Maine 1992). Women of high fertility are repeatedly exposed to risks and complications related to childbearing. Like maternal morbidity/mortality, fecundity and fertility vary both within and across populations. Biological, ecological, and social factors impacting fecundity and the number of live births women experience are well described elsewhere (Bongaarts 1978; Wood 1994; Ellison 2001). The following section discusses key relationships among maternal health and biological, ecological, sociocultural, economic and political factors.

3.3 Determinants of maternal health and fitness Biological factors Risks for maternal morbidity/mortality vary across the lifecourse, as risks and reproductive value changes over time. Age and reproductive status influence birth outcomes throughout the life course (Maine 1981). Risks for morbidity/mortality are highest for young women around menarche and older women nearing menopause. 37 Controlling for age, primiparas, and high parity women also experience higher risks of disability and death. The mortality curves for women by age and parity are “J/U”-shaped because risks are highest at the extremes but lowest for women of average reproductive age and parity (McCarthy and Maine 1992). Younger women have immature pelves, increasing their risk of obstructed labor. Risks of complications increase among older women. In addition to maternal morbidity and mortality risks, middle-aged women (35 years and older) experience declining fecundity, more fetal deaths and their offspring are more likely to have chromosomal abnormalities (Wood 1994). Complications such as uterine prolapse are also more common among high-parity women (Koblinsky 1995). In ecological settings where nutritional status is poor, births are closely-spaced, breastfeeding is prolonged and intense, and high parity is common, women’s energy reserves may become depleted (Tracer 1991; Winkvist et al. 1992; Adair and Popkin 1992). Young women reproducing soon after menarche face higher risks of nutritional deficiency because they are still supporting their own growth (King 2003). Micronutrient deficiencies also increase the consequences of complications arising during pregnancy and childbirth. Women with anemia experience more fatigue, infections, and death from severe bleeding (Alauddin 1986; Kandoi et al. 1991; Brock 1999).

Ecological factors In addition to agricultural strategies and cultural familiarity with environments, general ecology influences quantity and quality of food available. It also determines risks for exposure to pathogens and their vectors, along with environmental stressors. In populations large enough to support epidemics, density of settlement alters infectious disease loads (Dobson and Carper 1996). Environmental characteristics such as climate and altitude not only impact ecosystems, but also levels of heat, cold, and hypoxic stress, thereby affecting human health and

38 reproduction (Moore et al. 1998; Bronson 1995) Some stressors such as inadequate food or high infectious disease risks typically vary across environments and seasons (Ulijaszek and Strickland 1993).

Sociocultural factors Social circumstances influence women’s fecundity, pregnancy outcome, and fertility. Besides the physical environment, social setting alters access to resources, dietary intake, physical activity levels, exposure to and susceptibility to disease, and psychosocial stress (Pike 2001). Impacting the timing and outcome of reproductive events, social factors are important determinants of lifetime reproductive success. Women’s social status varies with individual traits, cultural factors, local conditions, and larger political and economic contexts. Level of education, occupation, personal income, age, ethnicity, general resourcefulness, and access to social support influence a woman’s status in both her family and her community (McCarthy and Maine 1992). Poorer women experience more maternal mortality and morbidity (Harrison 1997; Matthews 2002). By compromising immune function, psychosocial stress may influence short-term and long-term health (Dantzer and Kelley 1989; Glaser and Kiecolt-Glaser 1994). In combination with pregnancy- induced immunosuppression risks for infectious disease increase synergistically (Jamieson et al 2006). Physical, sexual, and psychological abuse during pregnancy increases poor health outcomes among women and children. Women who experience violence during pregnancy have double the risk for miscarriage and a fourfold increase in low birth weight infants (Koblinsky 1995). Larger cultural factors including perceptions of gender roles, rights, and duties, the value of women’s contributions to the family and society, norms regarding their access to resources and autonomy also impact an individual woman’s status (Das Gupta 1995). The status

39 of a woman’s family, in terms of members’ education and income levels, access to land and sociopolitical standing in the community, affects her access to resources for buffering her health (McCarthy and Maine 1992). Better educated women in wealthier households possess greater health knowledge and autonomy, while also having greater access to cash for healthcare.

Political and economic factors A community’s status within its larger regional and national context influences its ability to acquire medical care, health professionals, supplies, and healthcare facilities from the central government. Poor communities in sparsely populated areas often fail to receive adequate attention or financial support from national governments. This is the case for Miskito communities on the eastern coast of Honduras. At the international level, multilateral institutions, like the International Monetary Fund (IMF), often require that developing countries implement structural adjustment policies before they may borrow money or obtain debt relief (Welch and Oringer 1998). Too achieve these goals, government officials cut budgets for social services, leaving women and their families deprived of health care (AWID 2002; Dewan 1999). The highest rates of maternal mortality and morbidity are reported where women have little or no access to trained birth attendants, prenatal and postnatal health care (Ashford 2002). Trained health care providers attend approximately half of all births in less developed countries (Ashford 2002). In rural areas such as Miskito communities, doctors attend fewer than a quarter of all births. Lack of modern medical attendance typically occurs in a context of heightened economic stressors. Poverty, compromised “traditional” medical systems, and inadequate access to biomedical care interact to produce poor health outcomes.

40 Behavioral factors Behavior and biology interact to influence health, illness, and reproductive success (RS). A woman’s RS depends on her ability to produce children who survive and produce their own offspring. Behavior influences risks of fertility and mortality, while diet, activity patterns, and disease are influenced by physical and social environment and individual behavior. Women’s productive work may decrease or remain constant during pregnancy and lactation (Baksh 1994; Panter-Brick 1989). Heavy workloads increase nutritional requirements during pregnancy and lactation. Women may decrease energy expenditures or increase energy intake to meet excess demands (Dufour and Sauther 2002). Both activity levels and dietary intake are constrained by ecological and social factors in addition to larger political and economic forces. Women may also protect their children’s well-being and their own health by spacing births farther apart. Gambian women use contraceptives to buffer their health and future fertility, particularly after negative reproductive outcomes (Bledsoe et al 1998; Bledsoe 2002). Both biomedical and traditional health care behaviors and practices may buffer or jeopardize maternal and child health (McCarthy and Maine 1992). Still, women’s abilities to rear healthy children may be limited by specific cultural and economic constraints beyond their control (Scheper- Hughes 1984). Women’s use of and access to healthcare, for example, is linked to larger sociopolitical conditions which influence availablitity, type, and cultural appropriateness of local services.

3.4 Costs of Reproduction Reproduction is energetically costly for women. Extra energy required to support a pregnancy varies across populations, averaging between 240 kcal/day among European women in Scotland and the Netherlands to 70 kcal/day for Gambian 41 women (Dufour and Sauther 2002). Lactation requires more energy, particularly during the first three months, than does pregnancy. Costs may be 500 kcal/day during this period (Dewey 1997). Energetic stress and compromised health during pregnancy may negatively affect maternal and child survival and RS. Potential health consequences of reproduction are highest in energy-restricted environments, such as those typical of forager-horticulturalist groups, where women produce high numbers of offspring (Tracer 2002). In some populations, fat reserves (indicated by BMI, skinfold measurements) have been observed to decline with increasing parity (Tracer 1991; 2002). In populations with adequate calories, the costs of reproduction on maternal health are not clear. Frequent reproductive events may lead to micronutrient deficiencies and energetic burdens despite higher caloric intake. Infectious diseases such as malaria, tuberculosis, Chagas disease, and hepatitis and non-infectious diseases such as diabetes may be aggravated by pregnancy (Koblinsky 1995). Pregnancy also exposes women to hypertensive disorders (e.g., eclampsia), hemorrhage, obstructed labor, sepsis, chronic urinary tract infections, uterine prolapse, and vaginal fistulae, any of which may lead to death or disability (McCarthy and Maine 1992). Potentially women have options for meeting the demands of pregnancy. They may increase dietary intake, decrease physical activity, utilize fat reserves, become more efficient (muscular), and/or reallocate energy from basal metabolism and somatic maintenance (Dufour and Sauther 2002; Jasienska 2003; Prentice and Goldberg 2000). Use of these strategies often is limited by physiological and environmental factors and gender roles which reduce labor flexibility within the household. Important constraints likely include food availability, labor required for food preparation, metabolic ceilings (i.e., limits on increasing reproductive effort by increasing food intake), fat reserves, activity-related elevations of basal metabolic rate, and work demands (Jasienska 2003). 42 Evidence indicates that social and ecological conditions often limit energy intake during pregnancy and do not allow decreases in workloads (Das Gupta 1995; Panter-Brick 1989).

3.5 Life history theory Based in evolutionary biology, life history theory predicts species-wide patterns in the timing of critical life events such as gestation length, age at weaning, age at maturation, age at first reproduction, birth intervals, age at senescence, and age at death (Stearns 1992). Life events and patterns of growth, development, and reproduction are linked to age-specific schedules of mortality and fecundity (Hill 1993). Natural selection favors a life history (LH) that maximizes lifetime reproductive success (Partridge and Sibly 1991). Variation in LH among species implies that natural selection favors different strategies for different conditions. Constraints, including the physiology of the organism and conditions characterizing the environment, lead to trade-offs between LH traits (Partridge and Sibly 1991). Physiological trade-offs (causes of individual plasticity) may be distinguished from microevolutionary trade-offs (genetic responses secondary to differential survival and fertility) as they occur during an individual’s lifespan as access to energy and patterns of energy allocation change (Stearns 1992). Despite diversity in LH strategies on earth, correlations between LH traits emerge regardless of phylogeny (Hill 1993). For instance, slow and prolonged periods of growth and development, a late age at maturity, and longer life span typically accompany one another (Crews and Gerber 2003). Over their lives, individuals must allocate resources differentially to growth and development, somatic maintenance, and reproduction (e.g., mate selection, reproductive effort, and parental investment) (Hill and Hurtado 1996; Charnov 1993; 43 Sterns 1992). Energy used for one function is not available for others. Although individuals may consciously choose to expend energy on one function, such as parental investment (PI) in offspring, primary energy allocation decisions occur at molecular and physiological levels (Hill 1993). Patterns of energy allocation and life history characteristics vary according to environmental constraints (Hill and Hurtado 1996). Most likely, natural selection favored the abilities to adjust life history to prevailing environmental circumstances among hominins (Hill 1993). This flexible LH pattern allows humans to respond to ecological stress with high behavioral, physiological, and developmental plasticity. Genetic control of LH, if it exists, is very loose. Mathematical models developed for other organisms rarely apply to humans because they fail to address the complexity of human behavior, culture, and global political and economic forces (Morbeck et al. 1997). Selection should favor energy allocation patterns that maximize lifetime fitness. However, due to constraints, optimal strategies may have high costs. LH theory assumes that resources, and hence energy, are limited. Evolutionary biologists and biological anthropologists focus on fitness/energy trade-offs among reproductive effort, somatic growth, and maintenance (Stearns 1992; Peacock 1991; Mace 2000). Researchers have identified over 45 different trade-offs between life-history traits (Hill and Hurtado 1996). However, most research has focused on potential trade-offs between current and future reproduction, current reproduction and survival/health, reproduction and growth, and quality versus quantity of offspring (Stearns 1992). The most important trade-offs may occur between current and future reproduction and between fitness and number of offspring produced (Hill 1993; Lessells 1991; Williams 1966).

44 3.6 Life history theory: maternal investment and reproductive costs Life history theory is useful for understanding the costs of reproductive effort and trade-offs between investments in children and maternal health. Without costs or constraints, individuals should invest unlimited resources in an infinite number of offspring, thereby maximizing their reproductive success (Partridge and Sibly 1991). In reality, for most humans, resources are limited and pregnancy and lactation are metabolically expensive and risky (Peacock 1991). Mothers often must choose between investing in current reproduction or their own maintenance. Decreased future survival or fertility secondary to impaired maternal health may result from effort expended on current reproduction (Williams 1966; Lessells 1991). Reproduction requires the diverting of energy from maintaining maternal health when food supplies are limited. Testing LH trade-offs among humans has proven difficult (Mace 2000). Yet, Tracer (1991) demonstrated that maternal nutritional stress was associated with parity in the malnourished Au population of Papua New Guinea. An energetic toll (maternal depletion) may accrue with repeated reproduction in food scarce societies. In populations with adequate food resources, costs of reproduction are less clear. Immune activity is an important component of maintenance (McDade 2003). Mace (2000) argues that the reallocation of energy from immune function to reproduction has not been firmly determined by human biologists. Given that pregnancy induces immuno-suppression to prevent rejection of the developing fetus, additional impairment of immune function may increase maternal infections and compromise health. Reproductive costs and associated energetic constraints likely existed throughout human evolution. This suggests that physiological mechanisms and reproductive strategies have evolved to increase women’s lifetime RS. Ovarian function is sensitive to environmental stress, and level of suppression is closely correlated with the duration 45 and severity of stress. These adaptive responses may protect women by reducing investment in pregnancies that are likely to result in poor outcomes or jeopardize their future reproduction (Ellison 1990; Jasienska 2003). Vizthum (2002) proposes a “flexible response model” with differential responses to acute and chronic energetic stress. If women delay reproduction indefinitely under conditions of long-term food shortages, this suppressive response may actually limit their lifetime RS. Pregnancy occurs even with limited resources. Under such conditions maternal investment in pregnancy may require multiple trade-offs. Patterns of maternal investment represent compromises between mothers and fetuses with competing demands and different strategies (Peacock 1991; Wells 2003). Although women and their offspring share half of their genetic material, maternal and fetal objectives and strategies differ throughout pregnancy. Fetal needs potentially endanger maternal health, survival, and future RS, whereas maintaining maternal health may place the fetus at risk. Natural selection favors patterns of energy allocation by mothers that maximize lifetime RS. Ensuring the success of the current pregnancy may negatively impact a woman’s lifetime RS (Peacock 1991). By stressing the importance of lifetime reproductive success, evolutionary models explain why a woman’s best interests are not always served by buffering her fetus from energetic stress. Hamilton (1966) and Fisher (1958) proposed that a woman’s reproductive potential (or value) influences her investment strategy. Age greatly determines reproductive value. Younger women should choose future over current reproduction in stressful situations because they retain greater potential than older women. Multiple mechanisms for reducing energy exchange between mother and fetus have evolved. For example, the rate of uteroplacental blood flow may be adjusted to deliver more or fewer nutrients to the fetus or gestation length may be shortened to avoid high energetic costs during late term pregnancy and switching to lactation, when 46 fat stores can be mobilized (Peacock 1991). While investigating supplementation effects during pregnancy in Guatemala, Winkvist et al.(1998) reported that very low weight women repleted themselves, rather than investing these nutrients in their next offspring. Fetal programming, a permanent metabolic response to poor nutrition in the fetus, has consequences for long-term health of offspring (Hales and Barker 1992). Flexibility is lost early despite potential environmental change and risk for later disease (Wells 2003). Smaller, metabolically efficient offspring require less food (Wells 2003); however, parental investment demands will most likely be higher for nutritionally-compromised children who have higher risks of morbidity and mortality. Mortality and population growth rates determine whether the actual cost of current reproduction for future reproduction is worth bearing (Hill and Hurtado 1996). If the probability of survival is low and population growth is rapid, future costs are discounted because the individual contributes more genes to future generations by reproducing early. Maternal mortality and morbidity can follow from investing in reproduction and incurring the physiological risks of pregnancy and childbirth at the expense of somatic maintenance and future survival. Maternal morbidity and mortality jeopardize or end a woman’s ability to reproduce in the future. If a woman is not able to invest in her previously born children she cannot help ensure their survival to reproductive age or allocate resources to her grandchildren. Thus, her lifetime RS and inclusive fitness may be limited. Based upon evidence about how traits interact and relevant constraints, LH theory predicts outcomes of trade-offs assuming that NS favors strategies that optimize lifetime RS. However, the expected trade-off may not be observed when traits in question are not heritable or when individuals vary in their access to energy, their efficiency of energy utilization, and/or their allocation of energy (Stearns 1992). Partridge and Sibly (1992) point out that while positive correlations among growth, somatic maintenance, and 47 reproduction complicate LH theory’s predictions regarding expected trade-offs, they also represent an important and perhaps not surprising result. Differential access to resources make predicting outcomes of trade-offs difficult. When individuals are successful at obtaining more resources, they can buffer themselves and their offspring from exposure to the environment and disease (Hill and Hurtado 1996). Thus, high fertility may be accompanied by high maternal and child survival among some individuals. Among individuals with high resource availability and/or the ability to use resources more efficiently, positive correlations among growth, maintenance, and reproduction may emerge for the population, thereby concealing the trade-offs that less-advantaged individuals experience (Stearns 1991; McDade 2003; Hill 1993; Mace 2000; Borgerhoff Mulder 1992; Partridge and Sibly 1991). Ideally, researchers should control for differences in phenotypes, genotypes, and resource access, but this is rarely possible in human studies. In low-resource settings positive correlations among growth, maintenance, and reproduction are less likely to occur (McDade 2003). However, even within resource-deprived communities individuals vary greatly in their access to resources. Careful consideration of how and why some women experience trade-offs and vulnerability to poor health outcomes, while others do not, may require measuring factors not needed to understand non-human life history theory models. Following LH theory, this research attempts to describe trade-offs between investment in reproduction and maintainence of maternal health. However, the environment is defined here as the complex physical, ecological, sociocultural, political and economic conditions under which women live. Environmental conditions are not uniform within populations. Sociocultural, political, and economic factors influence stressors individuals experience and their abilities to respond to stressors while maintaining their health (Leatherman 2005). Examining how individuals avoid LH trade-offs and invest in both reproduction and maintenance simultaneously provides 48 information regarding human adaptability and resilience. Combining evolutionary theory with biocultural and political economic perspectives that focus attention on factors that determine resource access leads to a more holistic understanding of human life histories.

49 CHAPTER 4

METHODOLOGY

4.1 The biocultural research model Genes, environment, and culture interact with biology to produce variation in growth, development, reproduction and health. Biocultural research examines these interactions by linking biological, demographic, social, political, and economic factors to individual and population health parameters. The inclusion of multiple variables in studies requires researchers to use varied methods to collect and analyze data. Research design depends on the specific interactions of interest (research question) and link theory, methods, data collection and analysis together (Johnson 1998; Pelto and Pelto 1996). Biocultural measurements include indicators of health and the physiological, social, nutritional and other factors that create and constrain health and well-being (Wiley 1992). If health refers to physical, mental and social well-being as stated by the World Health Organization, a multitude of factors potentially influence specific outcomes. Given such a broad definition of health, the biological, cultural, and socioeconomic factors researchers choose to measure depend on population- specific environmental conditions. Hypotheses regarding relationships among these specific factors and measures of growth, reproduction, disease and demographic patterns guide research design. Although the focus on the interplay between biology and culture through the analysis of multiple, complex factors is holistic, it also presents a challenge. Causal factors interact in complex ways, so distinguishing

50 independent effects of one factor on health is difficult. In other words, biocultural researchers must deal with many confounding factors. When estimating the effects of psychosocial stress on health confounding factors including nutrition, physical activity, and disease also must be measured. A biocultural approach was particularly useful in this research because maternal health is influenced by myriad factors – from individual characteristics to specific cultural beliefs of a society to global-scale political and economic forces that affect resources availability in the community. Women face a multitude of health problems. Explaining variation in health status within a population and elucidating the specific factors that put women at risk for poor health outcomes depend on identifying relevant stressors and evaluating how women respond biologically and behaviorally to the forces that potentially endanger their lives. Women’s responses to these risk factors are constrained by biological limitations, social norms, and access to material and non-material resources (e.g., income, social support, education, healthcare). To adequately address the complex issues related to the production of maternal health an equally complex and holistic research design is necessary.

4.2 Project Design This research project was designed to investigate maternal health in communities where women are vulnerable to maternal morbidity and mortality owing to widespread poverty, inadequate access to healthcare, and discrimination based on ethnicity and gender. The primary research question asks whether producing many children takes a toll on women’s health in this high-risk environment. The production of health or poor health occurs through the interaction of biology, culture, environment, and larger political and economic forces. To understand this biocultural process the research design included diverse methods drawn from both cultural and biological 51 anthropology. Interviews and health assessments provided important information about fertility, lifestyle, and health. However, 12 months of participant observation in Miskito communities also generated data on gender roles, cultural norms and values, and women’s daily lives. Such data are essential to seeing “the faces behind the numbers” (Dettwyler 1998: 399) and providing an emicly valid picture of maternal health in this setting. Because of this dual (biocultural) approach, the biomedical data from health assessments may be situated within their proper cultural context. Biomedical approaches preference Western ideas regarding disease, health, and healing and may not be relevant in other cultural contexts. Singer (1998: 105) describes biomedicine as “a core institution of capitalist society and as a system that reinforces dominance at the microsocial level”. Critical perspectives reject biomedicine’s objectivist, universalist, mechanistic and often reductionist way of understanding and treating disease (Singer 1998; Lock and Scheper-Hughes 1996). However, given biomedicine’s global pervasiveness, completely rejecting the approach is problematic. Instead, integrating biomedical, biocultural, and political economic approaches allows examination of multiple and varied factors that influence health.

Establishing the research site A preliminary visit to Honduras from August 21 – September 12, 2003 informed this project’s original design. This initial trip to Honduras allowed me to establish contacts with agencies, researchers, and community members and to investigate sizes and numbers of communities, and logistical details such as sampling considerations, distances between villages and transportation availability. Following my preliminary trip, funding was secured from the Wenner-Gren Foundation for Anthropological Research Inc. and permission to conduct this research was was received from The Ohio State University Internal Review Board, Human Subjects 52 Committee (see Appendix A). From November 2004 through November 2005 I completed twelve months of data collection during fieldwork in coastal Miskito communities along the Ibans lagoon, department of Gracias a Dios, Honduras. Approximately 5,000 people live in these communities. Meetings with support staff and directors of MOPAWI (a non-governmental development organization in the Mosquitia), AFE-COHDEFOR (governmental agency responsible for forest management in Honduras), and the Río Plátano Biosphere (BRP) Project occupied the first two months. During this period research permission was granted from the Honduran Institute of Anthropology and History (Instituto Hondureño de Antropología e Historia). After my arrival at the village of Belen in January 2005, MOPAWI continued to provide logistical support as I familiarized myself with the communities. This included meeting with leaders in the community, explaining my research goals to community members, listening to their concerns and suggestions, and ultimately recruiting and training local research assistants.

IRB procedures My local assistants were chosen because they understood the project’s goals and were sensitive to issues of participants’ confidentiality. Assistants could speak, read, and write in Spanish and Miskito. All assistants were women, and two had nursing training.

Although none were employed at a health center, the two nurses periodically performed health evaluations and provided care and injections to community members. Therefore, my assistants knew many members of their communities personally and were already trusted and respected. All research assistants participated in data collection and research ethics training (including the importance of consent, confidentiality, and sensitivity). Assistants organized community meetings and translated during all discussions with potential participants. This included statements regarding goals, purpose, research design, and criteria/requirements 53 for participation. All participants in this research provided informed consent through these assistants, who also explained the positive and negative aspects of participation as required by the Human Subjects Committee of the Institutional Review Board (IRB). Participants read or were read the IRB-approved consent form which was translated from English into Spanish. They were asked if they had any questions about the consent form information and their roles in the study. I asked all potential informants if they were willing to discuss personal issues related to maternal health, socioeconomic status, and social support during interviews and if they had any problems with researchers taking their height, weight, temperature, hemoglobin concentration, heart rate, blood pressure and skinfold measurements. Participants were reminded of the time commitment necessary for participation and asked if they understood their roles in the study and the consent information. All informants were reminded that their participation was voluntary and they could choose to stop participating at any time without penalty. A translator was present during these discussions to help answer questions and ensure that participants understood their roles and information on the consent form before they signed.

Issues of positionality and reflexivity The preliminary visit to the research site served to identify health issues that were of interest to women and community members. Likewise, throughout the data collection phase, the concerns women voiced continued to guide research questions. To collect quality data, the potential effect of the researcher’s position, one of power and prestige (a “wealthy” North American), was addressed in various ways. I was open, honest, and willing to answer any questions or clear up any misconceptions about myself. I asked women to discuss their opinions and experiences and explained there was no right or wrong answer to the questions. At first, women reported 54 believing that I would disagree or disapprove of their answers based on their perceptions of my cultural biases (for instance, about women’s desired family sizes). However, over time most participants understood my goals and were willing to share very personal information. Through sharing stories about ourselves, our friends, and our families we often found ourselves discussing how many struggles women share in common, no matter where they live.

4.3 Focused group discussions Next, focused group discussions were held in each community. Participants were recruited for specific group interviews based on age, gender, and residence. We met in public spaces (e.g., schools/schoolyards and churches) and women were served beverages and a snack. After explaining the research goals and obtaining consent from participants, a local field assistant and I asked participants open-ended questions about pregnancy, childbirth, and maternal morbidity and mortality. Focus group data were analyzed to explore cultural perceptions regarding environmental challenges women faced and specific obstacles for maintaining health. To examine perceptions about maternal health among women, men, local midwives, nurses, and doctors in the area, informal interviews were also conducted throughout the fieldwork period. Interviews conducted at the time of maternal deaths in the community allowed me to investigate individuals’ perceptions of mortality events when confronted with a specific case. Thus, I was able to observe peoples’ responses to maternal death immediately after it occurred, rather than depending on recalled experiences and perceptions.

55 4.4 Individual interviews More than two hundred women from twelve communities/hamlets participated in this study. The original selection criteria included women: a) over the age of 15, b) who had experienced at least two pregnancies, and c) who are not currently pregnant. However, some women were pregnant during the original interview (either unknowingly or unwilling to admit their reproductive status based on a fear of sorcery – see chapter 5) and others became pregnant during the study. At least thirteen participants were pregnant sometime during my research. Excluding women with less than two pregnancies prevented biasing the sample toward lower fertility. Women were sampled to include all age and parity groups (including high parity women) to estimate fitness trade-offs across the reproductive span (Table 4.1). Given the selection criteria of having experienced two pregnancies, the number of participants aged 15-19 years is lower than for other age cohorts. This study was designed to sample women from all twelve communities/hamlets as participants. Although villages are within walking distance of one another (and sometimes contiguous), available resources (e.g., health centers, schools, water systems) vary across communities. Rather than a random sample, the goal was to recruit a sample representing the variety of experiences reproductive-aged women have had in villages along the Ibans lagoon.

56 Table 4.1 Participants in the study of maternal health

Each participant completed two semi-structured interviews. Interviews were conducted with participants to collect basic information on demographic, reproductive, and developmental events along with life history and household economics. Reproductive histories included age at menarche, marriages/partnerships, pregnancies and deliveries (including dates, outcomes, problems, birth attendants, care after birth), current reproductive status, breastfeeding, contraceptive use, and preferences regarding child spacing and family size. To capture potential generational variation in reproductive values and behaviors, women from all age groups, even some who had yet to complete their reproductive years, were sampled. Health histories, and questions eliciting self-reports of health, along with information on the presence, intensity, and duration of chronic and infectious diseases and pain were obtained during initial interviews. Participants also reported household composition (number, age, sex), education level, employment/subsistence activities of household members and socioeconomic status. Other adults in the household verified

57 participants’ reports. Data on women’s employment, household wage earners, family income, land holdings and use, and ownership of material goods and productive assets, as well as perceived economic security of the household were also reported. Women reported their formal educational attainment, ability to travel on their own and freedom to make independent decisions. Questions were directed at control of household income, use of health care, and contraceptive issues as these reflect autonomy. Women reported when, how, and who they depend on during times of need. Social network interviews elicited frequency, type, and duration of exchanges during the past month, following a method proposed by Hanna (1998). A woman’s standing in her community reflects both her social status and her ability to draw on social support from others. Therefore, all women reported their involvement in community activities and organizations.

4.5 Health assessments Health assessments were conducted after each interview. The following information was collected.

Temperature, Blood pressure, and heart rate Temperature was measured in degrees Celsius using a LifeSource UT-202 Instant Read Ear Thermometer. An Omron HEM-712C Blood Pressure Monitor provided readings of women’s systolic and diastolic blood pressure and heart rate (in beats per minute). Women were sitting during individual interviews for at least thirty minutes before my research assistant or I measured their blood pressure and heart rate. They were seated comfortably, usually on a stool or plastic chair, with legs uncrossed. Two blood pressure and heart rate readings were recorded.

58 Body composition Anthropometry was used to obtain height, weight, and body composition measurements reflecting nutritional status (e.g., skinfolds and circumferences). These measures are reliable for estimating nutritional status and are widely used by biomedical researchers worldwide (Giles and Friedlaender 1976; Frisancho 1999; Lohman et al. 1988; Evelth and Tanner 1976). All anthropometric measurements reported here followed methods described by Lohmen et al. (1988) and were taken on the right side of the body only. Measuring devices were cleaned with alcohol after each use. I measured upper arm, waist, and calf circumference with a fiberglass tape measure in centimeters twice, and my research assistant recorded the measurements. Mid-upper arm circumference was measured at the upper arm’s midpoint, between the acromion process and the olecranon process. The tape measure was placed around the body, midway between the lower rib margin and the iliac crest to measure waist circumference. For medial calf circumference, participants sat with their legs bent and feet flat on the ground. The measurement was taken midway between the proximal and distal processes of the tibia, at the maximum circumference of the calf. Skinfold measurements included the biceps, triceps, subscapular, suprailiac and medial calf regions. A Lange® caliper was used to measure each skinfold to the nearest millimeter. Three measures taken consecutively at each skinfold site were averaged to mitigate the effects of intra-observer error (Lohman et al. 1988). To prevent inter-observer error I performed all skinfold measurements. Tricep skinfolds were measured at the midpoint of the back of the right upper arm and bicep skinfolds at the front upper right arm. Subscapular skinfolds were measured below and lateral to the angle of the right scapula. Suprailiac skinfolds were taken at the midaxillary line above the iliac crest.Intra-observer error for all measurements was examined using ANOVA. For each site, all three skinfold values for each individual were included in ANOVA models to analyze variation among individuals and within individuals’ 59 measurements. The mean square error represents average variance between measures for each individual in millimeters2 and the square root of the mean square error provides the average difference among measurements for individuals in millimeters. For the triceps skinfold site, average error in millimeters was 0.72; for bicep skinfolds, 0.32 mm; for subscapular skinfolds; 0.50 mm; for suprailiac skinfolds, 0.85 mm; and calf skinfolds, 0.40 mm. I measured participants’ heights twice with a GPM anthropometer. Participants stood up with their backs straight and heels together. Measurements were recorded to the nearest millimeter. Research assistants and I weighed women twice, to the nearest half kilogram, with a portable health-o-meter scale placed on a stable, flat surface. Notes regarding participants’ clothing were taken when weight was recorded. The scale’s estimated margin of error was within 100 grams. Indicators of body composition were calculated from height, weight, and skinfold data. Body mass index (BMI) refers to weight in kilograms/height in meters2. Based on international classifications, women with BMIs under 18.5 kg/m2 are considered underweight, 18.5 to 24.9 kg/m2 are normal, 25.0 to 29.9 kg/m2 are overweight, and 30 kg/m2 or higher are classified as obese (Frisancho 1999). Women with waist circumferences greater than 88.0 cm are also considered obese (NHLB 1998). Sums of skinfolds were calculated by totaling the measurements for all skinfold sites.

Anemia status A portable HemoCue® Hemoglobin B photometer was used to measure hemoglobin concentration in a sample of capillary blood. One of my research assistants, a trained nurse that works in the community, performed the test by obtaining a drop of blood from a finger stick (using a sterile, disposable Stat-Let Auto lancet) to measure hemoglobin concentration in grams per deciliter. This method is accurate to ±1.5 % and correlates at 0.99 with the reference method 60 (ICSH method) (HemoCue 1991). Microcuvettes, lancets, gloves, and alcohol wipes were stored in a biohazard waste receptacle until they could be burned and buried. Hemoglobin concentration was measured twice for monthly participants, once during the moratorium on lobster diving, at the beginning of the wet season and again after the moratorium, at the end of the wet season. On two occasions, as a community service, free anemia screenings were offered to adult women at the local health clinic. Pregnant and non-pregnant women of various ages, 100 of whom did not participate in the study presented for testing. Their hemoglobin data are included in this analysis as part of chapter 7 (Body composition, hemoglobin concentration, and blood pressure levels). These women reported their age, reproductive status, and parity when they were tested. Women who attended free anemia screenings were only measured once. Anemia was classified based on World Health Organization criteria as hemoglobin concentration below 12.0 g/dl in non-pregnant women or 11.0 g/dl in pregnant women (controlling for hemodilution) at sea level.

4.6 Follow-up interviews Follow-up interviews focused on dietary intake, workload/activity, social support, household decision-making, illnesses, and health-seeking behavior. Attempts were made (e.g., multiple visits to the household) to complete interviews and health assessments twice for all participants. Four women moved or were away from their homes for extended periods (e.g., visiting family members, pursuing economic opportunities) and could not be re-contacted. Following initial interviews, 59 participants were re-visited once a month for six months. Data on health, household economics, social support, diet, and activity were recorded at each visit. Six months includes household economic variation before, during, and after the 4 month government moratorium on commercial fishing. Data obtained during these interviews included: 61 Morbidity: Women recalled episodes, duration and intensity of illnesses experienced during the previous month.

Food and activity patterns: At each follow-up interview, participants recalled their dietary intake and time allocation during the past 48 hours. Dietary recall, a widely used, non-intrusive method, involves a structured interview during which participants list the types and quantity of food they consumed (Chapman et al. 1994). Reports were supplemented with food frequency questionnaires. Questions also elicited data on access or lack of access to specific foods (e.g., beef, vegetables) and changes in food security and workloads from month to month. This information was combined with anthropometric data to examine nutritional status. Likewise, women were asked to report their time allocation to work and leisure activities during the previous morning, afternoon, evening, and night and during the day of the interview.

Access to and use of health care: Women reported perceptions regarding access to health care and its quality. They recalled their use of health care clinics and hospital visits during the past month. This included health care for themselves, their children, or other household members.

Social support, stress and economic security: Women reported who helped them and who they helped with food, money, work, childcare, and advice during the past month. They also listed any stressful events occurring during the past month (e.g., conflicts with others, illness or accidents, problems with children), whether they experienced problems sleeping or with their appetite, along with the perceived causes of these problems. In response to open-ended questions during interviews, women discussed 62 changes in household economics and their abilities to meet household needs (e.g., food acquisition, school fees, health care, and other necessities) since our last visit.

4.7 Survey of maternal mortality To collect data regarding maternal mortality, women age 15 and older who were living in the communities along the Ibans lagoon in the department of Gracias a Dios, Honduras were interviewed using the sisterhood method (Graham et al 1989). They were asked about the number of sisters they had who had at least reached the age of 15, and if they were living or had died due to causes related to pregnancy or childbirth. If women reported a maternal death further information regarding the circumstances of the death was collected. Fifty-five maternal deaths were reported by family members. Reports of maternal deaths included the age of the deceased woman, the date of her death, where, and when the death occurred (i.e., during which month of pregnancy, during birth, how long after birth), the cause/s of her death, whether she received prenatal care or experienced complications in the past, who attended the birth, birth outcome, previous number of live births, and caretakers of orphaned children. Original reports were cross- checked with other living sisters and family members.

4.8 Data analysis

Observational data Data collected during participant observation are included throughout the results chapters. Observations regarding events that occurred in the study communities during fieldwork, behavior of men, women, and children and the conditions of life for women in these Miskito villages provide ethnographic context. These observational data enrich information obtained by structured interviews, anthropometric, and biomedical techniques. Interpretations of biomedical data may 63 be of more value when situated within the day-to-day activities and cultural context of peoples’ lives. Physiology is influenced by local cultural values and norms, regional political and economic processes, and national/international factors. Semi- structured interviews with representatives from government agencies, employees of non-governmental organzations, local community leaders, healthcare providers, and village members provided information regarding these larger scale forces that influence health and well-being.

Descriptive statistics Descriptive statistics for all variables relating to women’s age, parity, household and individual socioeconomic status, contraceptive use, morbidity experiences, body composition, blood pressure, and hemoglobin concentration are presented in results chapters and summarized in Table 4.2 and Table 4.3. Means, medians, variances, and standard deviations for continuous variables were calculated and graphs (e.g., histograms, box plots) were constructed to describe their distributions. Frequency calculations serve to describe characteristics of households, biodemographic features of the sample, and prevalence of health problems among participants. Rates of fertility, parity progression ratios, and infant and under age 5 mortality were also calculated to demonstrate trends in vital rates. Mean completed family size averages the number of live births women age 45 and older have experienced to estimate fertility (Wood 1994). Age-specific fertility rates (ASFRs) offer useful measures of fertility that also include the reproductive experiences of women who are still bearing children (Wood 1994; Hill and Hurtado 1996). Rates are calculated by dividing the total number of births to women in each five year age cohort by the total number of years each woman spent in the cohort. The average number of births women experience in each cohort equals this rate multiplied by the number of years in each age cohort (by convention, cohorts 64 include 5 year intervals). The sum of the age-specific fertility rates for each cohort provides an estimate of total fertility, or the average number of live births women experience during their lives if they conform to age-specific fertility rates (see Wood 1994 for an explanation of this method). Parity progression ratios estimate the probability that a woman will have an additional child given a specific achieved parity. Using parities of women who have completed childbearing, the ratios are calculated by dividing the number of women who go on to experience at least one more live birth by the total number of women who achieved each parity. Age-specific rates for probability of death were calculated based on mothers’ reports of live births, ages, and survivorship of children elicited during reproductive history interviews (see Howell 1979 for a discussion of this method). Estimates of the probability of death are based on the number of children who died before reaching age one and age five, divided by the total number of children at risk of death. Individuals who have yet to complete the time interval are censored in the denominator.

Dependent and independent variables used to test hypotheses

Hypothesis 1. Biodemographic and socioeconomic factors significantly explain variation in fertility among Miskito women. Dependent variables: Gravidity, parity Independendent variables: Age, age at first reproduction, menarche and

marriage, socioeconomic status, education level, contraceptive use, duration of breastfeeding, social support, place of residence, autonomy in decision-making, ideal family size preferences

Hypothesis 2. Investment in reproduction reduces women’s health. Dependent variables: Body composition (Body mass index, skinfolds, circumferences), systolic and diastolic blood pressure, hemoglobin concentration 65 Independent variables: Gravidity, parity, reproductive status (pregnant, lactating, non-pregnant and non-lactating, post-reproductive), past experiences of morbidity during reproductive events Control variables: Age, socioeconomic factors, Reproductive status (when the independent variable is gravidity, parity, past morbidity experience)

Hypothesis 3. Biodemographic and socioeconomic factors influence women’s health. Dependent variables: Body composition (Body mass index, skinfolds, circumferences), systolic and diastolic blood pressure, hemoglobin concentration Independent variables: age, household composition, socioeconomic status, wage earning, education level, contraceptive use, social support, place of residence, autonomy in decision-making, membership in community organizations, workloads, dietary intake Control variables: Gravidity, parity, reproductive status (pregnant, lactating, non- pregnant and non-lactating, post-reproductive), past experiences of morbidity during reproductive events

Definitions of continuous variables used in these analyses are located inTable 4. 2 and summary statistics are presented in Table 4.3. Definitions and summary statistics for categorical variables are located in Table 4.4, Table 4.5, and Table 4.6.

66 Table 4.2 Continuous variables used in the analyses

67 Table 4.3 Summary statistics for continuous variables used in the analyses

68 Table 4.4 Categorical variables used in the analyses 69 Table 4.5 Summary statistics for categorical variables (excluding health indicators) used in the analyses

70 Table 4.6 Summary statistics for categorical health indicators

Bivariate and multivariate statistics SAS (SAS Institute Inc, Cary, NC) and Minitab (Minitab 14, Minitab Inc., State College, PA) software were used for all statistical analyses. Statistical methods included analysis of variance (ANOVA), Chi-square tests, and multiple linear regression analysis to investigate relationships among anthropometric, health, demographic, and socioeconomic variables. All data are presented with absolute p-values and 95% confidence intervals.

71 For continuous variables (e.g., hemoglobin concentration, body composition variables, parity), I used chi square tests to investigate significant deviations from normality. Exponential or logarithmic transformations were used if variables’ distributions were non-normal. One-way ANOVA tests were used to identify significant differences in hemoglobin concentration among means for groups (e.g., age cohorts, socioeconomic stratus, education level, community of residence). Levene’s test for equality of variance served to confirm that variances among groups were not significantly different before analysis. Chi square and likelihood ratio Chi square tests were used to investigate significant differences between groups for anemia, a categorical variable. Given potential correlations among many biodemographic and socioeconomic variables, multiple linear regression was the primary analysis used to examine relationships between dependent and independent variables and test hypotheses 1 through 3. Stepwise linear regression provided the models for explaining variation in fertility, BMI, circumferences, skinfolds, hemoglobin, and blood pressure given the independent variables mentioned previously. Results chapters provide additional (and more specific) descriptions of data analysis for each dependent variable. Multiple factors - genes, cultural values, age, household demographics, and access to material and non-material resources - potentially influence both reproduction and maternal health directly. Biodemographic and socioeconomic factors may also indirectly affect the production of offspring and maternal well-being due to the complex interplay between maternal health and reproduction. Reproduction may influence maternal health outcomes and likewise, maternal health status may influence reproductive outcomes (see Figure 4.1).

72 Genes Cultural values

Access to Age Reproduction non-material resources

Access to Household demographics material resources

Maternal health

Figure 4.1 Factors influencing reproduction and maternal health

73 CHAPTER 5

THE MISKITO ETHNOMEDICAL SYSTEM

5.1 Medical pluralism The Miskito people draw on multiple medical systems for defining the causes of poor health, diagnose illness, and heal or cure health problems. The Miskito word for illness or poor health, siknis, is derived from the English word ‘sickness’. Explanatory models for poor health depend on the type of illness individuals experience. According to Foster’s (1976) classification of disease etiologies, the Miskito ethnomedical system is both naturalistic and personalistic. People believe that some illnesses result from actions of a person, ancestor, spirit or deity; while other illnesses result from natural forces or conditions (e.g., cold, heat, air, wind). In turn, the appropriate therapy for treating illnesses depends on the etiology of the siknis. This chapter briefly describes the pluralistic medical system of the Miskito people with special attention to beliefs and practices related to pregnancy and childbirth.

5.2 Etiology of siknis Despite changes in beliefs, the incorporation of Western biomedicine, and conversion to Christianity by missionaries, ideas regarding personalistic etiologies have persisted. Most Miskito people believe that supernatural creatures and spirits, witchcraft, and sorcery cause health problems. These agents may strike when people do not follow culturally-constructed norms of behavior (e.g., they overexploit

74 environmental resources, see Fagoth et al. 1998) or through no fault of their own (e.g., bad luck, being in the wrong place at the wrong time). These illnesses, like biomedically-defined diseases, represent significant sources of stress in peoples’ lives. Spirit creatures, or lasa, include for example, the liwa (spirits of the water), unta dukia (spirits of the mountains/forest), swinta (owner of the deer), wahwin (a badly-smelling creature that prowls around at night), and prahaku (owner of the wind) (for descriptions see Fagoth et al. 1998; Cox 1998; Dennis 2004). Community members describe the liwa, for example, as mermaid-like creatures who live in the lagoon, rivers, and sea. People encounter these spirits when they bathe, swim, or dive for lobster. Informants explained that liwa mairin (i.e., the female mermaid creature) causes paralysis in divers because the sea creatures belong to her and she becomes angry when men harvest them. Other creatures that appear similar to cats or large iguanas can cause headaches, vomiting, fever, and even death in people who cross their paths. The Miskito people have incorporated these creatures into their own distinct form of Christianity (see Dennis 2004) and use the Bible to explain their origins. Informants often told me the same story that Dennis (2004) also heard in Nicaragua. When God banished Satan (Seitan) from heaven, he fell to earth and became the various evil spirits that live in the water, forests, and air. According to this explanation, the lasa are just different manifestations of ‘the devil’. People explain that since “God has come” to their villages, some of these spirits strike less frequently and fail to kill as many people as in the past “when they would walk among villagers and strike them dead on the spot”. For instance, in recent years epidemics of grisi siknis, a spirit-induced Miskito illness that primarily affects young women, potentially causing them to hurt themselves or others (described by Dennis 1981; 1985), have not occurred in these coastal communities. 75 Spirtits of dead people, called isingni may also return to cause illness, especially among relatives. Isingni do not necessarily intend to cause harm, they often return because of the love they feel for living relatives. Never-the-less, their presence affects people’s health. Typical symptoms relatives experience include fatigue, loss of appetite, weight loss and sometimes fever (see also Dennis 2004). The diagnosis of isingni siknis is often made if the ill person has recently experienced a death in the family. For instance, an eight year old boy suffered from a difficult case to cure after his mother died of AIDS. Also, one of the participants in this study discussed her ongoing isingni siknis caused by the spirit of her sister, a 16 year old woman who had died after giving birth to her first child just a few weeks prior to the interview. If food is left out overnight, spirits of the dead may look at, touch, or eat some of it. When living people eat the food they become sick with a dry cough or vomiting (bila puhban). Living people can also be agents of illness through the practice of witchcraft or sorcery. The Miskito typically refer to these causes of illnesses as “poison”, “trick”, or “trick poison”. A person’s food may be poisoned or poison may be buried under the intended victim’s path. Informants recalled that in the past poison put in waterholes/ wells killed many people. “Poison” is typically extracted from dead and decaying animals or by grinding bones into powder and may be accompanied by written spells (“trick”) when buried in the ground. Informants emphasized the danger inherent in eating food provided by strangers or people who may hold grudges or be jealous of others. For example, after unclear biomedical diagnoses and three unsuccessful surgeries, one woman firmly believed that the cause of her chronic illness was poison. She remembered accepting a coconut from a man who she had rejected as a lover in the past. He had set aside a “special” coconut for her, but she did not feel suspicious of this until after the onset of her health problems. 76 A person may fall victim to sorcery or witchcraft without being poisoned. People can use a variety of spells or secrets (often written on something the victim will come into contact with) to cause illness, infertility, and lower libido. Most people believe that potent spells can cause general unhappiness or restlessness among victims, others may provoke people to leave or return home urgently. For example, witchcraft or sorcery can cause victims to “hate” certain individuals for five to ten years before they remember that they actually “love” the person (misbara). Achieving this objective requires mixing salt from different houses with dirt from the cemetery and saying a spell before placing the mixture in the intended victim’s path. Natural forces can lead to health problems among Miskito people as well. Despite regional and local variation, humoral medicine, or beliefs about the importance of temperature and the balance of hot and cold for health and healing remain widespread in Latin America (see Currier 1966; Foster 1987; Tedlock 1987; Weller 1983). Likewise, in Miskito communities people believe that too much of one extreme (especially cold) or the shock of moving too quickly between hot and cold can cause illness. I was frequently warned not to bathe too soon after I returned home, tired and sweating after a day’s work. A cold bath, while my temperature remained high would lead to problems in the future with pain in the body and aching bones. Like cold, air can enter the body and cause sickness. Depending on where the bad air becomes trapped, the person feels pain and discomfort, usually in his/her chest, back, or neck. Lightening can also have lasting and dangerous effects on objects that it strikes. If lightening strikes a tree and a person passes by the tree, lives near the tree, or eats fruit from the tree his/her face may become swollen, he/she may develop a cough and lose weight. The future children of women who come into contact with this source of illness (alwana) can fall victim to these health problems as well. People also believe that physical agents can invade and inhabit the body, thereby causing illness. Worms, amoebas, niguas (small insects that lay eggs in a 77 person’s skin, causing pain and inflammation) and other parasites were frequently cited as agents of disease. Individuals with biomedical training as well as some members of the general population subscribe to germ theory as an explanation for a particular subset of diseases, and classify some as contagious. Community members discussed local epidemics of influenza and dysentery. People also describe mosquitoes as the vectors of malaria and implicate dirt and contamination (especially by animal waste) in illness causation.

5.3 Curing and healing illness Given the varied etiologies of sickness, an equally varied system for diagnosing and treating illness exists among the Miskito. Spiritual healers or shaman, called sukia by the Miskito, communicate with spirits to define the cause and find the cure for specific illnesses. People generally regard sukias with uneasiness and distrust because of their powerful ties to the spirit world. Although they can cure health problems, they can also cause them by helping spirits target their victims. During diagnosis and healing, the shaman is expected to discover the spiritual or human responsible for the illness. By identifying the person who used witchcraft or sorcery as a weapon against the victim, the healer then makes him/her vulnerable to retribution by the victim’s family. Brown (1989: 10; see also 1985) argues that shamanism “inspires its share of discontent” owing to the violence and death surrounding the profession. Traditional herbalists or curanderos use plants, rather than spirits to treat health problems. People use herbs to cure illnesses caused by spirits, sorcery, and natural forces. Community members believe that “Miskito medicine” can treat everything from poison to paralysis caused by the liwa mairin, to snakebites, or even the common cough. Healers typically boil herbal mixtures (usually different types 78 of leaves and roots) with water and patients inhale the vapors, drink the mixture, and/or bathe in the mixture. The ingredients of the herbal treatment depend on the particular illness. While some recipes are well-known and widely shared among relatives and friends, other therapies can only be found with the help of a traditional healer. Curanderos guard their knowledge of herbal medicine to protect their livelihood. They receive payments for diagnosing and treating illness. In addition to direct payment, these healers receive indirect material benefits as well.Curanderos generally instruct people to leave an offering for the plant that is used in the herbal treatment, which they later collect themselves. People also turn to biomedical treatment to cure health problems. Both national development efforts and foreign initiatives have brought health centers and hospitals to the Mosquitia region. Although sometimes used in ways biomedical practitioners would deem inappropriate, people often buy antibiotics and pharmaceutical pills for fever and the symptoms of respiratory infections if they can afford them. Moravian missionaries have historically used the provision of Western biomedical care to promote their primary goal of converting the Miskito people to Christianity (Dennis 2004). They also attempt to dissuade people from seeking the services of a sukia for health problems by likening their healing techniques to ‘the work of the devil’ and refusing to treat individuals who received their care. Today, sukia no longer practice (at least openly) in the communities included in this research project, although older people remember being frightened of them as children. Traditional herbalists do continue to use ‘Miskito medicine’ to cure health problems. Missionaries and converted community members do not target herbalists’ work for change in the same way that spiritual healers have been marginalized. The type of treatment people choose to pursue depends on what they believe to be the cause of their illness (e.g, a spirit, witchcraft, or natural forces). Only 79 “Miskito medicine” can cure spiritual or sorcery-induced health conditions. Both biomedical treatments and herbal remedies may be prescribed for illnesses caused by natural forces. In these cases, peoples’ decisions regarding type of treatment depends on advice received from relatives and friends, their past experiences, cost of the various treatments, and resources that families can mobilize to pay for healthcare. They may choose to employ herbal cures or biomedicine, or switch from one to the other if they witness no improvement, or use a combination of both simultaneously. Prayer is another strategy people use to heal themselves and others. Groups of people congregate to pray, sing, and hold vigils for sick individuals. In these cases, people say that God is the best doctor. Sometimes the cause of illness remains unclear. Symptoms of illnesses caused by spirits or sorcery often appear quite similar to biomedical problems or diseases. For instance, lobster divers are vulnerable to health problems owing to the dangerous conditions of their work. The symptoms of illnesses caused by the liwa mairin and decompression sickness both include paralysis and may quickly lead to death. When the exact cause of the health condition is unknown, people generally use different therapies simultaneously or choose the cheapest option available. In the case of decompression sickness versus illness caused by the liwa mairin, the typical course of action includes administering herbal remedies (i.e., “Miskito medicine”). If that proves ineffective, people assume the cause is decompression sickness. Treating decompression sickness requires more expensive and extensive biomedical care, which includes sending the ill man to a hospital. Most families cannot afford this type of treatment. People recognize that outsiders (especially those who practice Western biomedicine) may reject their ideas regarding the definitions, etiology, and appropriate therapies for certain types of illness. Never-the-less, traditional illnesses continue to be significant in their lives and represent serious threats to well-being. 80 5.4 Perceptions and use of Western biomedicine People attend local health centers most often for respiratory infections and stomach problems. Women typically visited the center for help with their children’s health problems rather than their own. Mothers reported diarrhea, respiratory infections, coughing, fever, and skin problems (rashes, abrasions, sores) as the most common ailments of their children. Adults report increasing incidences of biomedically-recognized conditions such as arthritis, hypertension, diabetes, cancer, and stroke. In many cases, people assume they suffer from these conditions based on their symptoms and knowledge of these diseases, but often lack the resources to obtain actual medical diagnoses. In general, people in these coastal communities desire better access to biomedical care. They complain about the lack of services and supplies available at local health centers, especially emergency medical care. Although they speak favorably about treatment available at hospitals in Puerto Lempira and Ahuas, the distance and cost of traveling to these facilities represent significant obstacles. Other barriers to use of biomedical care include limited hours of operation and perceptions that doctors and nurses (who are typically Miskito) treat healthcare as a “business” to make money and lack compassion for ill patients. In terms of biomedical treatment, people prefer injections over pills or prescribed dietary changes. People believe that injections work faster and more effectively than other types of therapy. Doctors and private nurses often prescribe injections of antibiotics or vitamins, but people also buy injections from local pharmacies without orders from healthcare practitioners. People take vitamin injections for pain, fatigue, and high blood pressure and often improperly use antibiotic injections for non-bacterial infections. Dennis (2004) found this same desire for injections among Miskito people in the village of Awastara, Nicaragua. 81 He describes the use of injections as abusive and dangerous (2004: 210). The same may be said for villages along the Ibans lagoon, where people regularly tell stories of allergic reactions to injections that nearly culminated in death for certain individuals. People believe that biomedicine can explain and diagnose their specific health problem when the cause appears to be natural conditions or natural forces. Since many people recognize the same conditions that Western biomedicine defines as disease (e.g., malaria, tuberculosis, hypertension), they also believe biomedical treatment to be effective in solving these health problems. Although community members perceive biomedicine as a powerful tool to use against illnesses caused by natural forces, it holds no force against spirits, witches, or sorcerers. Most people see biomedicine as complementary to traditional medicine. Within this integrated and pluralistic medical system both maintain utility, depending on the cause of disease. Given that people explain illness in different ways, without perceiving personalistic and naturalistic etiologies as incompatible, both herbal Miskito medicine and Western biomedicine serve important healing purposes.

5.5 Pregnancy, childbirth, and the recovery period Women, depending on their reproductive status, may be perceived as potential agents of illness. Pregnant women, just by their presence, can cause health problems among newborn babies. Therefore, they do not visit houses/rooms where mothers are resting with their new babies after giving birth. People say that the pregnant woman causes the newborn to struggle, become stiff, and contort his/her body. Dennis (2004) describes the symptoms of this illness (called wasakia munaia) as including vomiting, bleeding from the umbilicus, and failure to nurse as well. Likewise, people generally perceive menstruating women to be a danger to others, particularly men. During menses, women typically do not prepare food for their spouses or male 82 relatives, as people believe that eating this food causes men to lose their strength and become short of breath. Older women in the communities recalled that menstruating women left their families’ homes to stay in other houses where relatives would bring them food in the past. Early literature (Bell 1862; Conzemius 1932) supports their memories of this Miskito custom. The presence of menstruating women also decreases the effectiveness of herbal medicine (Dennis 2004). Informants explained that only virgins should serve food to someone suffering of a snakebite and sexual intercourse is particularly dangerous for recovering victims. Postpartum bleeding is treated like menstruation. Women should not cook or have sex with their spouses. Most couples practice abstinence for one or two months after birth. People also believe that women are susceptible to spirit-induced illness, witchcraft and sorcery, and biomedical complications. For example, male spirits may appear to adult women or older girls in dreams and sexually assault them. Upon waking they feel traumatized and complain of pain and body aches. Washing clothes or bathing in the “dirty” lagoon also increases health risks. The Liwas that inhabit the lagoon can cause vaginal problems and repeated miscarriages until women receive herbal treatment. Women’s vulnerability to illness increases during pregnancy, childbirth, and the postpartum period. Women rarely make public announcements of pregnancy because if people know about their status, this could invite attempts to use sorcery or witchcraft to harm mothers and/or their unborn children. Poison and trick tend to produce varied symptoms during childbirth including labor that does not progress, bleeding, and convulsions (similar to biomedical complications of obstructed labor, eclampsia, and hemorrhage). Nurses and doctors who practice biomedicine cannot effectively treat these problems. Instead, curanderos must be consulted to provide appropriate ‘Miskito medicine’. Given the dangers women face, community members encourage them to follow certain behavioral guidelines to protect their health and insure positive birth outcomes. 83 Pregnant women should eat nutritious food, especially meat, fish, and soup with plantains and bananas. However, this ideal may not be realized given limited family resources. Community members most often blame undernutrition and malnutrition on the high cost and lack of availability of quality food, not the lack of knowledge regarding nutrition. People believe that many of the foods a woman eats during pregnancy can affect the size and personality of the child. For example, women who eat watermelons and coconuts will have large babies. If the mother eats a piece of cheese that a mouse nibbled on, the child will like to hide things and will not help his/her mother. If she eats bird meat during pregnancy, the child will be talkative (like a parrot). Women tend to joke about these beliefs rather than avoid certain foods. During pregnancy, women are expected to continue their domestic labor. However, people encourage them to be careful and avoid falling or other trauma. Despite the fact that they continue to cook, clean, and do laundry, behavioral restrictions on carrying heavy objects often require them to depend on others for help. Women often told personal stories of miscarriages that occurred when they ignored behavioral guidelines and carried heavy bags of rice or baskets of wet clothing. Near the end of pregnancy, women’s activity generally decreases. Participants reported resting more often during this period and women in the last few weeks of pregnancy were often observed spending more time in hammocks or chairs. However, the extent of this change depends on whether relatives or friends are willing to share their workloads. Most women give birth at home, with the help of a midwife, relative, and/ or a private nurse. When no support person is available or the woman has hidden the pregnancy from family members (for instance if a woman goes into labor while she is working in an inland agricultural settlement or if she is young and unmarried), she gives birth alone. Men usually stay outside of the house during birth, but often remain within talking distance to monitor progress. Women give 84 birth lying in bed or on the floor, and sometimes midwives make stirrups with tree branches or other people help hold the laboring woman’s legs and knees. Some midwives, especially those who are also curanderas, use herbs to help labor progress (they place them on the woman’s stomach and/or the woman drinks the mixture) or castor oil. They use massage to try to change the fetus’s position or stop bleeding if necessary. Private nurses may use injections of pitocin to induce stronger contractions or to treat hemorrhage. Midwives reported that in the past, after delivery, they cauterized the umbilical cord with a hot machete and used castor oil to clean the umbilicus. Ideally, today midwives receive string, gauze, iodine, alcohol, and gloves from the health centers (though sometimes the lack of supplies prevents this). They boil their utensils, use scissors to cut the umbilical cord, and iodine to clean the umbilicus. Midwives clean but do not sew tears, which commonly occur among first-time mothers or in the case of large babies. Private nurses may give injections of antibiotics to prevent infection. A member of the woman’s family typically buries the placenta in the yard and plants a fruit tree for the child beside it. If the amniotic sack can be saved after birth this will bring the child good luck. Sometimes others will buy the dried sack, since whoever owns the sack can reap its benefits. Lobster divers believe they can increase their harvest if they possess this good luck charm.

Community members stressed the vulnerability of women to health problems during the postpartum period. To buffer against higher risks for illness, they encourage women to rest, eat well, and protect themselves from agents of sickness (whether natural or supernatural). Given adequate social support, for at least a month women should remain at home where their only responsibility is to care for the newborn. Other women (usually mothers, sisters, or daughters) take over their domestic responsibilities of cooking, cleaning, and laundry while they 85 recover. Women should focus on eating liquids and soups for the first few weeks postpartum (as opposed to “hard foods” which make bowel movements more difficult), but avoid salty foods and beans to prevent a large abdomen. Women also need to protect themselves from cold or air, which can enter the body and cause infertility, headache, and abdominal pain. Despite sometimes sweltering temperatures, they do this by wearing socks, warm clothes, a hat, or putting cotton in their ears. Likewise, women should not wash clothes or bathe in cold and dirty lagoon water. Venturing into the lagoon could expose women to cold, parasites, and Liwas. Instead, women should only bathe with warm water in their house. Community members attribute maternal health problems to not following these protective restrictions. Older women in particular criticize younger generations for not adhering to protective traditions.

86 CHAPTER 6

DEMOGRAPHIC INDICATORS OF LIFESTYLE, FERTILITY, AND HEALTH

This chapter describes demographic information, lifestyle, and indicators of maternal and child health for households that participated in this study. Summary statistics regarding age and sex composition of women’s households, household wage earners and subsistence activities, living conditions, material resources, social support, and decision-making are presented. Population-level fertility patterns and models that explain variation in fertility among individual women in Miskito communities provide information regarding women’s investments in reproduction. Demographic indicators of health for women and children in these communities are also included and compared with national level vital rates. Estimates of infant mortality, under age 5 mortality, and maternal morbidity rates are followed by a discussion of access to adequate healthcare, particularly during pregnancy, childbirth, and the puerperium.

6.1 Household demography

On average, 7.7 people live in participant’s households (n=218). Approximately half (49.7%) of household members are children under age 15, 43.3% are age 15-49, and 7% are 50 years or older. Just over half of household members are female (50.9%). Eighty percent (80%) of the participants live in their own homes

87 (n=176). Others live with family members (16.5%), most often with the woman’s mother (10.1%). A few participants (2.3%) rent homes as well. Most participants live with a partner, although the majority of unions are not legally-recognized marriages. About 86.2% of women have spouses, while 7.8% are unmarried, 1.8% are separated from their partner, and 4.1% are widows. Most participants follow the culturally ideal matrilocal residence pattern - 59.2% of women live in the same village as their mothers, generally within close proximity to their houses. Household demographic information is summarized in Table 6.1.

Household subsistence strategies Households use different strategies to meet economic needs (Table 6.1). The majority (42.7%) of households in the sample depend on wages male family members earn working at sea on lobster, shrimp or other fishing boats, and supplement cash income with agricultural production. Some families (27.5%) concentrate on agricultural production alone, producing food (rice, beans, manioc, bananas, plantains, etc.) for both consumption and sale to other local households, and working for wages on other people’s land. In 6.9% of households, at least one family member holds a professional job with a dependable salary (e.g., teachers, nurses, pastors). Eleven percent of households earn cash by providing other types of services (e.g., construction, collective transportation, fixing motors, bikes, radios).The remaining households (11.9%) lack a substantial wage earner and rely on low paying, sporadic wage opportunities (e.g., washing clothes, selling baked goods) or extended family members for cash and material goods. This category typically includes households headed by single women, retired people, or injured divers who can no longer work. Most participants live in modest, one-room houses constructed from wood, with few material belongings. Most houses are elevated, with a wood floor (69.3%), 88 while others are not elevated, and have dirt floors (19.3%) or cement floors 1.3%).(1 Roofs are typically metal (79.3%), though poorer families live in houses with thatch roofs (20.8%).

Household characteristics

Family size (mean) 7.7 Proportion of house members under age 15 (mean) 49.7% Proportion of house members 15-49 (mean) 43.3% Proportion of house members age 50 and older (mean) 7.0% Proportion of female household members (mean) 50.9%

Own home 80.0% Live in woman's mother's house 10.1% Live in other relative's house 16.5% Rent home 2.3%

Wood floor 69.3% Dirt floor 19.3% Cement floor 11.3%

Metal roof 79.3% Thatch roof 20.8%

Table 6.1 Household demographic information

89 * “Low-no” indicates the lack of a substantial wage earner in the household

Figure 6.1 Primary household wage earning activity

Regarding ethnicity, 84.9% of the participants identified themselves as Miskito, 11.0% identified as Miskito and one or more other ethnicities (i.e., Miskito and Ladino, Miskito and Pech, etc.); 3.2% as Ladino, and 0.9% self-identified as Garifuna or Garifuna and Ladino (Table 6.2). All women speak at least some Spanish, though fluency and comfort with the language varies. Teachers instruct classes in Miskito and Spanish during the first few years of primary school. Most non-Miskito women understand and speak some Miskito and Ladino children learn Miskito from their playmates. Some families choose to send children who want to continue their education beyond primary and middle school to live and attend classes in towns and cities outside of the region. Nineteen households in the study were supporting children who were studying away from home at considerable expense to the family. On average, women received 4.5 years of education, compared to a national average of about 5.7 years of education for women (INE 2001). Just under five 90 percent (4.6%) of women had no education, 59.2% attended some primary school, 28% completed primary school (6 years), and 8.3% have more than a primary education (Table 6.2). As the number of local schools increase and cultural values regarding education change, young women have more educational opportunities than previous generations of women. People consider men to be the principle breadwinners in families; however, 53.2% of women earn wages. Most of these women (85.3%) wash clothes, bake goods for sale, or sell produce from their gardens to contribute to household income. However, 14.7% make larger contributions to the family’s finances through their work in teaching, nursing, and running local stores or boarding houses. Many women (54.6%) also participate and hold positions of leadership in community organizations. For instance, about half of the participants (46.8%) reported belonging to a church. Other women serve on advisory boards or as treasurers, secretaries, vice presidents, and presidents of development and health projects or local education committees.

91 Description of the sample

Ethnicity (%) Miskito 84.9% Miskito and other group 11.0% Non-Miskito 4.1%

Marital status (%) Single 7.8% Married/in a union 86.2% Separated 1.8% Widowed 4.1%

Education Years of education (mean) 4.5 No education (%) 4.6% Some primary school (%) 59.2% Completed primary school (%) 28.0% More than primary school (%) 8.3%

Table 6.2 Summary statistics for participants

6.2 Fertility Demographic indicators of women’s fertility in communities along the Ibans lagoon are derived from reproductive histories of 218 women. Women in these Miskito communities show high rates of fertility. The mean completed family size of women 45 years and older is 8.2 live births (n=51). Table 6.3 and figure 6.2 show age-specific and total fertility rates for this sample (n=218). Age-specific fertility rates (ASFRs) increase steadily up to age 20, reach their peak at ages 20-29, then steadily decrease. The total fertility rate (TFR) is 7.7 live births per woman. If women conform to ASFRs they will produce just under eight children during their lives. The

92 difference between the completed fertility rate of 8.2 and the TFR of 7.7 reflects a fertility decrease in more recent generations compared to older generations. This fertility decline is modest; women continue to bear high numbers of children relative to other populations. Parity progression ratios (PPRs) were also calculated to examine the effect of current family size on future reproduction. PPRs included data from women age 45 and older (n=51) and women who have been sterilized (n=43) regardless of age (total n=94). A PPR represents the proportion of women who have achieved a given parity and go on to produce one or more children (Wood 1994). Table 6.4 and figure 6.3 show the PPRs for this sample. Natural fertility populations generally have PPRs that decrease slowly and are convex upward, while controlled-fertility populations are concave upward and decrease more rapidly (Wood 1994). This sample’s PPRs fall somewhere between these patterns as the curve is slightly concave up to a parity of 7, but thereafter becomes convex. Wood (1994) argues that the parity-dependent nature of fertility control, women choosing to stop reproduction when they reach a desired family size, leads to the differences between these curves. Miskito women voice a preference for stopping reproduction rather than spacing births farther apart (e.g., becoming sterilized rather than using oral contraceptives or injections). However, not all women have a specific family size or parity target they prefer. Instead, family size preferences change with age, marital status, maternal health, and family resources. The availability and acceptability (or lack thereof) of birth control options also influences spacing and stopping behavior.

93 Age cohort Fertility rate 10-14 0.05 15-19 1.29 20-24 1.78 25-29 1.78 30-34 1.42 35-39 0.99 40-44 0.34 45-49 0.00

Total 7.65

Table 6.3 Age-specific and total fertility rates (n=218)

Figure 6.2 Age specific fertility rates (n=218)

94 Parity PPR 1 1.00 2 1.00 3 1.00 4 0.93 5 0.90 6 0.86 7 0.79 8 0.81 9 0.77 10 0.64 11 0.48 12 0.40 13 0.25

Table 6.4 Parity progression ratios (n=94) Proportion of women of Proportion

Figure 6.3 Parity progression ratios (women 45 years and older and sterilized women of any age, n=94) 95 Fertility rates in these Miskito communities are higher than national and departmental averages (Table 6.5). However, comparisons of TFR should be made with caution. National and department fertility rates are based on census data from the year 2001, while this sample uses retrospective data to calculate TFR. If fertility rates among women in Miskito communities have decreased recently, the inclusion of older women in the sample may be causing an overestimate of fertility. In contrast, the same method was used to calculated the mean completed family sizes (MCFS), average number of live births to women 45 and older, for all three estimates. MCFS provides a better comparative indicator, though still imperfect given potential problems with census data (e.g., underreporting births, less coverage of remote areas) (for a discussion of census data limitations see Kennedy and Perz 2000; Layton and Patrinos 2006).

Year TFR MCFS Source Honduras 2001 4.2 6.3 INE 2001 Gracias a Dios 2001 5.7 6.4 INE 2001 Miskito communities 2005 7.7 8.2 Reproductive histories, n=218

Table 6.5 Total fertility rates (TFR) and mean completed family size (MCFS) - national, department, local estimates for Miskito communities along the Ibans lagoon

A completed fertility rate of 8.2 and TFR of 7.7 ranks high even among natural fertility (i.e., non-contracepting) populations. TFRs of natural fertility populations typically range from four to eight live births with an average of six (Wood 1994). In Miskito communities, the use of contraceptives and sterilization has decreased fertility rates from over eight births in the early 1990s (Dodds 1994;

96 1998) to just under eight births in 2005. Table 6.6 shows a comparison of ASFRs for 2005 and 1992. Fertility rates in 2005 are slightly higher from age 15 to 29, but each cohort thereafter (ages 30 to 49) has lower ASFRs than those calculated for 1992. Presently, women appear to be spacing children closer when they are younger (age 15-29) and having fewer children after age 30. The lower rates of fertility in later cohorts are responsible for the modest decrease in fertility in the 13 years between surveys. Changes in fertility appear to reflect parity-dependent stopping behavior rather than longer birth spacing across the reproductive span.

Age cohort 2005 ASFRs 1992 ASFRs for Belen * 10-14 0.05 0.09 15-19 1.29 1.20 20-24 1.78 1.75 25-29 1.78 1.63 30-34 1.42 1.48 35-39 0.99 1.42 40-44 0.34 0.49 45-49 0.00 0.51

Total 7.65 8.56

* Source: Dodds 1994

Table 6.6 Comparison of ASFRs for Miskito communities in 2005 and 1992

Proximate, intermediate, ultimate determinants of fertility Why are fertility rates for Miskito communities in this sample so high? This section examines the determinants of fertility rates using frameworks that identify and organize major factors that influence variation in fertility. Demographers have developed 97 different models to categorize the almost infinite number of biological, sociocultural, political and economic factors that impact fertility. The proximate or intermediate determinants approach (Davis and Blake 1956; Bongaarts 1978; Wood 1994) identifies a few specific determinants of birth intervals and the overall length of the reproductive span. All other forces must act through the proximate determinants to create variation in fertility. These factors directly influence fertility and are usually divided into exposure to intercourse and conception and susceptibility factors (e.g., ovulation, fetal loss, gestation length) (see Wood 1994 for a comparison of different models). Specific determinants in relation to the Miskito population are discussed below. Common exposure factors include age at menarche, age at marriage, and the proportion of women married (Bongaarts 1978; Wood 1994). These factors influence women’s risks of conception by determining when women enter their reproductive years and begin to engage in sexual intercourse. Based on participants’ reports, the average age at menarche was 13.7 years (s.d.= 1.3) and age at first marriage/sexual union was 16.4 (s.d.=2.4). The average age at first pregnancy, 17.1 years (s.d.=2.5), occurred soon after marriage. The vast majority of women (86.2%) were married/living with a partner. In general, Miskito women begin to reproduce early in comparison to both natural fertility populations and controlled fertility populations. For example, Ache, !Kung, and Yanomami women start bearing children between eighteen and nineteen years of age (Hill and Hurtado 1996; Howell 1979; Melancon 1982). Women of different indigenous groups in Antioquia, Colombia typically give birth to their first child between age 16 and 18.1 (AriasValencia 2001). Average age at first birth among Mayan women in Mexico dropped to 19.5 years after the introduction of labor-saving technology (Kramer and McMillan 2006). In comparison, the average age at first birth of US women is approximately 25 years (Mathews and Hamilton 2002). 98 Suppression of ovulation during breastfeeding, referred to as lactational amenorrhea, is often lauded as the most important determinant of postpartum infecundity and therefore, a “powerful birth spacing mechanism” (Wood 1994; 339). Duration of lactational infecundability appears to depend partly on nutritional status and energy expenditure, but also on breast-feeding patterns (Wood 1994; Valeggia and Ellison 2001). The majority of women in Miskito communities nurse children on demand and report breastfeeding infants for one year. By one year of age, children can walk and eat food; in other words, mothers judge their development as sufficient to begin weaning. Women commonly stated that their need for mobility or a new pregnancy were also reasons to wean infants. However, the actual duration of lactation shows tremendous variation. Women’s reports of duration of breastfeeding ranged from two months to three years with a mean length of 14.7 (s.d.=5.8) months. Ninety-seven percent (97%) of women breastfed all of their children. Six women did not nurse one (or in one case, two) of their infants because the children refused to breastfeed or their milk supply was judged insufficient. Some women purposely continued to breastfeed in order to prolong lactational amenorrhea, while others complained that despite breastfeeding, their menses returned within a couple months after birth. Both primary and secondary sterility limit individual women’s total fertility

(Wood 1994) . None of the women in the sample suffered from primary sterility, all had experienced at least one live birth. Never-the-less infertility represents a problem for some women in the communities. Seven women reported long-term problems conceiving despite having produced one or more children in the past. Infertile women in Miskito communities often adopt children when their attempts to use modern or traditional medicine to improve their fecundity fail. Their treatment options are limited given the lack of testing facilities and medical supplies at local health centers. The presence of 99 sexually transmitted disease may influence the age at onset of pathological sterility (Wood 1994). Women often report experiencing symptoms associated with chronic reproductive tract infection (e.g, abdominal and lower back pain, vaginal discharge, pain during urination). Despite high fertility rates, the Miskito people are not a natural fertility population. At the time of the study, 45.4% of the participants reported currently using hormonal contraceptives or were sterilized, 54.6% were not using any method of birth control. The most popular method of birth control in use was sterilization (60.6%) followed by injections (22.2%) and then oral contraceptives (16.2%). After excluding women over age 49 from the analysis (n=190), 48.4% of reproductive age women were presently using birth control. All women could name at least the most common forms of modern birth control available, including oral contraceptives, injections, and sterilization. While 27.7% of women had never tried any modern form of birth control, 72.3% were using contraception or had tried one or more methods in the past. Women also reported that homemade mixtures could be used to induce abortion or prevent future conception (including treatments with various local herbal medicine and Epsom salt [sal inglesa]). More remote or ultimate determinants of fertility influence women’s exposure and susceptibility to pregnancy and birth. Women’s decisions to use birth control, for instance, depend on their ideas regarding ideal family size, their current health status, and their social and economic needs. Whether birth control methods are affordable, available, acceptable, and approved by their spouses must also be considered. Large families are the cultural ideal, as children provide help in the household, security in old age, and company for their parents throughout their lives. Women often discussed the precarious situation low fertility creates. One woman explained “What if you only have two children and they both die? Or, they could both be worthless and refuse 100 to help their parents. This would be like having no children at all”. However, the increasing costs of feeding, clothing, and educating children have led many women to state a preference for limiting family size. They cite low job opportunities, the difficulties of providing necessities for many children in today’s economy, and an increase in social problems (e.g., alcohol abuse, drug trafficking) and disease (e.g., HIV/AIDs) as reasons to have fewer children than in the past. When asked about their ideal number of children, women gave answers that ranged from as low as one to as high as 20. Women’s responses reflect their opinion at the moment they were being interviewed. The mean ideal number of children is five (n = 217; s.d.=1.93). Five children would still represent high fertility, but their responses imply an unmet need for family planning services given that TFR is 7.7. Dodds (1994) also found a lower desired family size (6.3 children) compared to the 1992 TFR of 8.6 and suggested that family planning services could be effective tools in decreasing unwanted fertility and population growth. However, it remains unclear how much of women’s fertility is actually “unwanted” despite their reported preference for smaller families. Fertility decisions depend on many different, dynamic factors (e.g., household age and sex composition, partnerships with men, current economic circumstances, current health status, access to contraceptives). Condoms are available in the region, but appear to be an unpopular method of birth control. Only one woman reported that she and her husband used condoms regularly. Women explained that men preferred not to use condoms because of their association with less physical pleasure and the need to protect partners against sexually transmitted infections. The burden of contraception thus falls mainly on women. Presently, health centers do occasionally run out of birth control pills or injections and cannot provide many different contraceptive options for women. However, at least one form is usually available at low cost. For example, at one health 101 center women can receive a three-month injection for the price of a consultation, five Lempiras, or about $0.28). Many women stop using contraceptive pills or injections due to side effects they experience. Women reported a variety of problems including abnormal bleeding (or lack of menses), headaches, weight gain or loss, abdominal pain, and dizziness associated with pills and/or injections. There is also a widespread belief that hormonal contraceptives cause cancer in addition to the previous side effects. Medical research supports these beliefs to some extent (IARC 1999). Perceived risks prevent some women from trying these methods or using them regularly. Instead, some women choose to forego contraceptive use until they reach a desired family size and then become sterilized. Though less-often associated with sin (refusing to accept all the children God gives them) and side effects, sterilization is not without perceived health risks. The financial costs of transportation to a hospital, room and board, and the surgery may also limit women’s abilities to choose this option. Women’s preference for sterilization fits well with underlying ideas regarding child spacing and the biological risks women face as they senesce. When asked during structured individual interviews about the ideal amount of time between pregnancies, women on average reported that 3.5 years (n = 215; s.d. = 1.4) would be less work and better for the health of the mother and both children. However, open- ended discussions of this question during individual interviews and focus groups usually produced a different view. If women spaced their children this far apart, they would continue to reproduce into their 40s to reach desired family sizes. Instead, many stated that having children rapidly, in close succession to finish childbearing sooner and become sterilized made more sense. Although this strategy means high workloads for women who have many young children, they experience these workloads when they are younger and more energetic. The perceived risks of spacing 102 births closely earlier in life are lower than reproducing at older ages. Women believe that older mothers are more likely to experience complications during pregnancy and childbirth and are less able to recover from potential health problems. For women over age 45 and those who have become sterilized, the mean age at last birth, 33.5 years, is well before women’s biological abilities to reproduce end. Just as Gambian women used contraceptives to rest or recover after reproductive mishaps (Bledsoe et al. 1994; Bledsoe 2002), Miskito women use birth control to preserve their own health when they believe reproduction reaches the highest costs. Yet, these strategies contrast markedly from advocates of family planning who focus on birth spacing to maintain maternal and child health (PIP 2002). Their recommendation of ‘three to five saves lives’ does not fit cultural perceptions of risk or local realities. Miskito fertility is neither out of control nor abnormal in comparison to other indigenous groups in Latin America. Despite the typical focus on the consequences of population growth by advocates of population control, high fertility rates documented among indigenous populations may help ethnic groups accomplish sociocultural, political, and economic goals (McSweeney and Arps 2005).

Intrapopulation variation Fertility varies not only between populations, but also within populations

(Wood 1994). Focusing on average fertility rates conceals variation among individuals. Women in this sample have experienced one to fourteen live births (n=218) and variation in parity increases with age. What then are the factors that create differences in fertility among women in Miskito communities? Linear regression was used to create a model to explain fertility variation. The influence of age, age at first pregnancy and marriage, contraceptive use, socioeconomic status, education, wage earning strategies, autonomy, and social support on parity 103 were analyzed. The best fitting model using stepwise regression included age, low socioeconomic status, not presently using any birth control method, breastfeeding duration, age at first pregnancy, and currently married. Together, these variables explain 68.3% of the variation in fertility among individuals (Table 6.7). Age, low socioeconomic status, not using birth control, and marriage are positively associated with fertility. The strong relationship between age and fertility (see figure 6.4) indicates that women who have spent more time in their reproductive years have higher fertility. Non-contracepting women do not limit their exposure and susceptibility to pregnancy and therefore experience higher fertility. Married women’s exposure to pregnancy is also greater, assuming they engage in sexual intercourse at higher frequencies than non-married women. Low socioeconomic status must act through direct determinants to increase fertility. For instance, intentional and non- intentional behavioral strategies used by poor women may lead to higher fertility. As expected under the proximate determinants framework, duration of breastfeeding and age at first pregnancy are negatively associated with fertility. Breastfeeding children for longer periods of time can delay the resumption of ovulation after pregnancy, thereby increasing birth intervals and reducing the overall number of reproductive events over a woman’s reproductive years (Wood 1994). Likewise, women who marry and initiate childbearing at older ages have fewer reproductive years to produce children.

104 Predictor Coef SE Coef T P R2 Age (Log10) 17.52 0.86 20.29 0.000 55.4% Low SES 0.51 0.27 1.89 0.060 55.9% Not using birth control 0.50 0.23 2.22 0.028 56.8% Breastfeeding duration -0.04 0.02 -1.88 0.062 57.3% Age at first pregnancy -0.39 0.46 -8.49 0.000 67.8% Married 1.27 0.34 3.71 0.000 69.2%

Adjusted R2= 68.3%

Table 6.7 Multiple linear regression model for fertility (n=218) Parity

Figure 6.4 The relationship between age and parity

105 6.3 Health indicators Infant and under age five mortality Reproductive histories were used to calculate morbidity and mortality rates. This section discusses infant mortality, under age five mortality and maternal morbidity rates during pregnancy, birth, and the postpartum period. On average, the 218 women sampled experienced 5.6 live births. Infant and child mortality rates typically serve as indicators of population health and economic development (see UNICEF 2006). Monitoring and improving child health have received international attention and targets for reducing child mortality are included in the Millennium Development Goals (UNDP 2003). However, many regions continue to fall short of making progress toward the goal of reducing child mortality by two thirds from 1990 to 2015 owing to inadequate prevention and treatment of health conditions (WHO 2005). Of the 1,225 live births reported, 65 infants died before reaching age one and 12 more children died before age 5. Probability of death was calculated by dividing the number of infants/children who died by the total number of children at risk of dying for each age cohort. The infant mortality rate (IMR) for this sample is 54.7 deaths per 1,000 live births and the under age 5 mortality rate is 74. 5 deaths per 1,000 live births. In comparison, the 2005 IMR and under-5 mortality rate for the country of Honduras were

31 infant deaths per 1,000 live births and 40 child deaths per 1,000 live births respectively (UNICEF 2006) (Table 6.8).

106 Year IMR <5MR Source Honduras 2005 31.0 40.0 UNICEF 2006 Department of Gracias a Dios 2001 27.6 32.3 INE 2001 Village of Belen 1992 88.2 * Dodds 1994 Communities along the Ibans lagoon 2005 54.7 74.5

Table 6.8 Infant mortality rates (IMR) and under-5 mortality rates (<5MR) - national, department, and village levels, various years

The higher IMR and under-5 mortality rate in these Miskito communities compared to national rates for Honduras reflect the difficult circumstances faced by women and children in the region. Lack of obstetrical care, laboratory testing, prevention and treatment of common infections contribute to poor health outcomes for women and children in these communities. Women reported infection or symptoms of infection as the cause of about half of all deaths. One-fourth of the causes of death were unknown and the other 25% occurred due to various causes (e.g., accidents, witchcraft or sorcery, refusal to eat). The higher infant and under-5 mortality for this sample may also be explained by the time depth of the measurement (see also Dodds 1994). Some deaths occurred over twenty years ago and therefore do not reflect current trends observed at the national level. National childhood mortality rates are derived from deaths in one given year rather than deaths summed from reproductive histories. Likewise, estimates for this sample exceed the 2001 infant and under-5 mortality rates for the department of Gracias a Dios which were 27.6 and 32.3 deaths per 1,000 live births (INE 2001). Underreported births potentially influence mortality rates calculated at the department level. Given that the births of many children who survive are registered late or not at all in this region, underreported deaths may also

107 present a problem for estimating mortality. Also, the small sample size of this study (n=218 reproductive histories) may inflate the rates of death. Dodds’ (1994) estimate of IMR for the village of Belen was similarly high compared to contemporary rates for the department and country. However, his IMR estimate of 88.2 calculated from data collected in 1992 is higher than the IMR of 54.7 for this sample. The difference between these estimates may be the result of improvements in infant and child health over the 13 years between data collection. Furthermore, differences in sample size may be influencing the results. Dodds (1994) calculated IMR based on the reproductive histories of only 77 women.

Maternal morbidity Like infant and child mortality rates, maternal mortality ratios are often used as indicators of development by international agencies (Goodburn and Campbell 2001; WHO 2004). However, maternal morbidity occurs ten to one hundred times more frequently than maternal death (Bhatia 1995). Given that maternal deaths are rare events even in regions with comparatively high maternal mortality rates, maternal morbidity deserves more attention (Filippi et al. 2000; Fortney and Smith 1996; 1999). Health problems that do not culminate in death never-the-less decrease short-term and long- term maternal well-being. Documentation of health complications during pregnancy, parturition and the puerperium are necessary to quantify the toll that investing in reproduction takes on women’s health. This research project included the first survey of maternal morbidity among women in Miskito communities along the Ibans lagoon. Calculated frequencies of specific complications allow for reports of multiple problems during a single pregnancy, birth, or postpartum period (Figures 6.5 - 6.7) . Women reported 1,286 pregnancies and 1,225 live births during reproductive histories. Participants recalled experiencing 36 miscarriages (includes one ectopic 108 pregnancy), 40 stillbirths, and 15 sets of twins. Twins are counted as only one pregnancy, but each infant is recorded as a live birth or stillbirth. Over half (53.7%) of the women had experienced morbidity during pregnancy at least once, 71.6% reported complications during at least one birth, 62.4% had experienced health problems during at least one postpartum period, and 36.2% reported experiencing morbidity during all three phases at least once during their lives. Table 6.9 shows the total number and frequency of health problems reported during pregnancy, childbirth, and the postpartum period. Women reported morbidity during gestation in 298 of the 1285 total pregnancies (23.2%). The most common symptom experienced during pregnancy was pain (22%), with abdominal pain in particular accounting for 11% of the problems reported. Women reported vomiting and nausea (severe pregnancy sickness) as the second most common health problem during pregnancy (18%) and swelling of the feet, hands, or veins as the third (11%) (Figure 6.5).

Figure 6.5 Reports of morbidity during pregnancy

109 Complications occurred during 26.5% of the births reported. The most common complication reported was prolonged or obstructed labor (65%) (Figure 6.6). Prolonged labor is defined here as labor lasting more than 24 hours. Obstructed labor is one cause of prolonged labor and refers to the failure of the fetus to move into the birth canal, often due to cephalo-pelvic disproportion, malpresentation or malposition of the fetus (Dolea and AbouZahr 2003). In 39 cases doctors performed cesarean sections in hospitals. Women reported 53 instances of private nurses in villages using injections of oxytocin (pitocin) to induce stronger contractions. Abnormal bleeding accounted for 16% of the complications reported and retained placenta for 10% (Figure 6.6). Four percent (4%) of the health problems during birth were symptoms associated with hypertensive disorders of pregnancy (high blood pressure, convulsions, swelling). Preeclampsia and eclampsia are rarely diagnosed biomedically in these villages.

Figure 6.6 Reports of morbidity during childbirth

110 Women experienced health problems during 24.3% of the postpartum periods reported. Lower abdominal pain was the leading cause of postpartum morbidity (38%). Women also commonly reported abnormal bleeding (27%), fever (22%), pain in the lower back or other parts of the body (5%) and infection (4%) (Figure 6.7).

Figure 6.7 Reports of postpartum morbidity

111 Table 6.9 Pregnancies, birth outcomes, and morbidity reports during reproductive events

Results indicate that women experienced maternal morbidity during pregnancy, childbirth, and/or the puerperium during one out of every four reproductive events. These morbidity rates are most likely underestimates of the complications women actually experienced since they are based on recall data from reproductive histories. Women are less likely to remember health problems during reproductive events that occurred in the past, in some cases, over twenty years ago. Despite their potential shortcomings, these estimates do point to an ongoing need to improve maternal health outcomes. All of the leading causes of morbidity reported here are preventable or treatable given adequate access to healthcare. However, obstetric and gynecological care for women in these communities remains limited. During interviews, midwives stressed the importance of extending access to training and assistance with emergency complications to them given the number of births they attend. For instance, doctors only attended 19.4% of the

112 births reported. The other 80.6% of births were attended by midwives or private nurses (64.3%) or family members with no healthcare training (16.2%). During health histories, women linked chronic health problems, particularly lower abdominal and back pain, with their reproductive efforts. They often stated that bearing and raising children exacts a toll on their long-term health. Pregnancy and birth are hard on the body and children “suck their blood” and weaken them. The perception that children demand great energy from their mothers fits well with the belief that closely spacing children when women are younger and have more energy is preferable to longer birth intervals that require more time to reach desired family size. This prevents women from taking the biological risks associated with childbearing at older ages and keeps workloads lower later in life when women begin to experience the cumulative costs of reproduction and senescence. Women also explain their illnesses in relation to their domestic and productive work. For instance, some women reported lifting heavy loads of laundry or carrying agricultural produce as the probable causes of miscarriages. They also attributed chronic aches and pains to long hours working in the sun, often in uncomfortable positions while washing clothes, working the fields, cleaning, or cooking over hot stoves. Workloads varied over women’s lifecourses. They reported the heaviest workloads when they had many young children, especially when children are still in diapers. Women with female children eventually experience a decrease in their workload when their daughters reach about age 10 or 11 years. This decline often continues as girls take on more responsibilities as they mature. In addition to health problems associated with work, women reported worrying, “nerves”, inability to sleep, and lack of appetite associated with conflicts in the household (e.g., an abusive spouse, teen-aged children who drink too much alcohol) and economic insecurity. Given their roles of ensuring household survival, questions about how they will feed, clothe, and educate their children often occupied their thoughts. 113 CHAPTER 7

BODY COMPOSITION, HEMOGLOBIN STATUS, AND BLOOD PRESSURE

Chapter 6 demonstrated that Miskito women invest heavily in reproduction, on average experiencing just under eight live births during their lifetimes. This investment in reproduction can lead to maternal morbidity directly related to pregnancy, childbirth, and the puerperium. But does it also influence other indicators of maternal health? In this chapter, indicators of maternal health including body habitus, hemoglobin concentration, and blood pressure are examined for relationships with reproduction and socioeconomic and biodemographic factors among women in Honduran Miskito communities. Descriptive statistics for each health indicator are presented to indicate population-wide parameters of maternal health. Multiple linear regression analysis is then used to estimate influences of biological, demographic, and socioeconomic factors on these health measures. Results are then used to determine significant factors impacting women’s biology and adaptive strategies.

7.1 Body composition Adult stature reflects nutritional status during growth and development as individuals must allocate sufficient energy to achieve genetic potentials for height. The mean stature for women in the sample is 152.8 cm, with a range of 140.1 to 170.3 cm. Compared to other indigenous populations in Latin America, these women are taller. For example, the mean height of women in the acculturating Suruí ethnic

114 group in Brazil is 146.5 cm (Santos and Coimbra Jr. 1996). Young Mayan women measured 146.9 cm on average (Bogin et al. 1992). However, in general Miskito women are shorter (just over the NHANES fifth percentile) than US women whose mean height is 163.1 cm (Bogin 1999).

Population Stature Source Suruí, Brazil 146.5 cm Santos and Coimbra Jr. 1996 Mayan, Guatemala 146.9 cm Bogin et al. 1992 Miskito 152.8 cm This sample U.S. 163.1 cm Bogin 1999

Table 7.1 Comparison of stature across four populations

Body mass index (BMI) was calculated as weight in kilograms divided by height in meters2. Excluding pregnant women, BMI ranged from 17.9 to 56.4 kg/m2 with a mean of 29.6 kg/m2 (n = 207; s.d. = 6.62) (Table 7.2). BMI is grouped into underweight, normal, overweight, and obese categories (Frisancho 1999). Only two of 207 non-pregnant women were classified as underweight for BMI (BMI less than 18.5 kg/m2), while 27.5% were normal (18.5-24.9 kg/m2), 29.8% were overweight, and 42.7% were obese (30 kg/m2 or higher) (Table 7.3). Within the obesity category all three classes are represented (Table 7.4). Of all women, 21.3% have class 1 obesity level (30- 34.9 kg/m2), while 14.5% belong to class 2 (35-39.9 kg/m2), and the remaining 6.8% are in class 3 (40 kg/m2 or more). Risk of hypertension, diabetes, and cardiovascular disease progressively increases from the overweight category through all three obesity classes (NHLB 1998). However, these cut-offs are somewhat arbitrary, and risk varies among individuals and populations (NHLB 1998).

115 Mean s.d. range Height (cm) 152.82 5.63 140.1-170.3 Weight (kg) 68.75 15.36 37.5-126.8 BMI (weight/height2)* 29.55 6.70 17.9-56.4 *Excludes pregnant women

Table 7.2 Sample height, weight, and body mass index (n=218, BMI n=207)

Table 7.3 Sample weight classification by BMI group for non-pregnant women (n = 207)

Table 7.4 Prevalence of class 1, 2, and 3 obesity among non-pregnant women in the sample (n=207)

For Honduras, the prevalence of overweight and obesity was 55.5% in 2002 (WHO 2007). In comparison, 72.5% of women in Miskito communities are overweight or obese. Mean BMI for women in Honduras is also lower at 25.7 kg/ m2. These results provide evidence that overweight and obesity among women in 116 Miskito communities is outpacing increasing rates at the national level. Santos and Coimbra Jr. (1996) suggest that Native American populations become fatter with social differentiation. Women report eating more imported and processed foods (e.g, vegetable shortening) while their agricultural workloads have declined as families concentrate on men’s wage labor at sea for subsistence. Women explained that men in these communities prefer to work at sea and buy goods with their wages rather than produce food themselves. Women may be particularly sensitive to acculturative changes in diet and workload, and therefore gain weight rapidly (Friedlaender and Rhoads 1982; Crews and Mackeen 1982). This change in nutritional status puts women at risk of chronic health problems associated with obesity including hypertension, diabetes, and cardiovascular disease. Obese women also suffer sex- specific risks including amenorrhea, infertility, hypertensive complications during pregnancy, gestational diabetes, prolonged labor and higher rates of caesarean sections (Linné 2004). Stepwise linear regression was used to analyze the substantial amount of variation in women’s BMI for this sample. Multiple regression identified age, meat consumption, mid-high socioeconomic status (SES) (3 on a 4 point scale), dependence on extended family members for wages, and living in the community of Betania as positively associated with BMI. Professional employment (of the woman or her spouse), living in the village of Payabila, and having experienced proportionately more morbidity during previous pregnancies are negatively related to BMI. Table 7.5 shows the multiple regression model for BMI by socioeconomic, biological, residence, dietary, and health factors.

117 Predictor Coef SE Coef P Age (log 10) 0.1935 0.0679 0.000 Meat 0.0219 0.0077 0.005 Midhigh SES (3) 0.0475 0.0178 0.008 No wage earner 0.0338 0.0192 0.081 Professional employment -0.0557 0.0245 0.024 Payabila -0.0661 0.0294 0.026 Pregnancy morbidity -0.0278 0.0128 0.032 Betania 0.0649 0.0338 0.056

R-Sq = 24.5% R-Sq(adj) = 21.2%

Table 7.5 Linear regression model for BMI (log 10 BMI), non-pregnant women (n=207)

Circumference and skinfold measurements are summarized in Table 7.6. Skinfold measurements are high for all five sites. Mean tricep skinfold falls in the 75 percentile of NHANES reference data for US women (1988-1994). The mean for subscabular skinfolds among women in Miskito communities is in the 95 percentile of US reference data and likewise, mean suprailiac skinfold is in the 85 percentile. Another measure of body composition, specifically body fat reserves, was calculated by summing the skinfold measurements from five different sites – tricep, bicep, subscapular, suprailiac, and medial calf skinfolds. Skinfold sums ranged from 44.3 mm to 238 mm, with a mean of 141.85 mm (Table 7.6). For non-pregnant women mean arm circumference was 34.27 cm, waist circumference averaged 94. 26 cm, and calf circumference was 36.22 cm (Table 7.6). As a measure of abdominal fat, waist circumference is also used as an indicator of obesity. Women with waist circumferences greater than 88.0 cm are at higher risk of diabetes, hypertension, and cardiovascular disease (NHLB 1998). Excluding pregnant women, 63.5% of women in the sample fall into this category (n=203). 118 Measure Mean s.d. range Circumferences (cm) Arm 34.27 4.80 22.6-46.1 Waist 94.26 13.84 65.2-137.4 Calf 36.22 3.88 21.9-49.7 Skinfolds (mm) Triceps 29.55 9.40 8.7-51.7 Biceps 17.85 7.71 3.0-38.0 Subscapular 38.31 12.98 9.3-71.7 Suprailiac 32.56 10.60 5.3-54.0 Calf 23.58 8.29 8.7-45.7 Sum of skinfolds 141.85 43.52 44.3-238.0

Table 7.6 Circumference and skinfold measurements for non-pregnant women (n=203)

Stepwise linear regression was used to examine factors significantly associated with circumferences and skinfold measurements. Only a few of many independent variables analyzed for relationships with arm circumference, waist circumference, calf circumference, and sum of skinfolds consistently appear significantly associated with measures in body habitus (Tables 7.7 – 7.10). Meat consumption and midhigh SES are positively related to all four measures. For arm circumference, waist circumference, and sum of skinfolds, age is a positive predictor. Morbidity rates during pregnancy and professional employment of the woman or her spouse are negatively associated with these dependent variables. These five independent variables are significantly related to BMI also. Living in the village of Payabila is negatively associated with arm circumference, waist circumference, sum 119 of skinfolds, and BMI. Payabila is a small village with no health center or access to improved water sources. Results suggest that age, socioeconomic status, type of employment of the primary wage earner in the household, dietary intake, and women’s experiences during reproduction are particularly important to understanding variation in body habitus among women in Miskito communities (Tables 7.5, 7.7 – 7.10).

Predictor Coef SE Coef P Age (log 10) 0.1501 0.0411 0.000 Meat 0.0134 0.0048 0.006 Pinales -0.0628 0.0196 0.002 Pregnancy morbidity -0.0238 0.0080 0.003 Midhigh SES (3) 0.0293 0.0112 0.009 Number of partners 0.0122 0.0042 0.004 Betania 0.0540 0.0212 0.012 Professional employment -0.0361 0.0152 0.019 Post-reproductive -0.0275 0.0135 0.043 Average household age 0.0011 0.0006 0.052 Belen -0.0188 0.0106 0.078 Payabila -0.0324 0.0184 0.079

R-Sq = 30.4% R-Sq(adj) = 25.8%

Table 7.7 Multiple linear regression for arm circumference (log 10), non-pregnant women (n=203)

120 Predictor Coef SE Coef P Age (log 10) 37.88 6.86 0.000 Midhigh SES (3) 7.09 2.50 0.005 % of household members <15 18.12 6.85 0.009 Average household age 0.31 0.17 0.069 Meat 2.09 1.07 0.054 Payabila -9.55 4.16 0.023 Pregnancy morbidity -2.64 1.79 0.141 Professional employment -5.15 3.45 0.137

R-Sq = 28.9% R-Sq(adj) = 25.8%

Table 7.8 Multiple linear regression for waist circumference, non-pregnant women (n=203)

Predictor Coef SE Coef P Midhigh SES (3) 0.0375 0.0090 0.000 Meat 0.0075 0.0039 0.057 No wage earner 0.0354 0.0118 0.003 Partners 0.0072 0.0035 0.040 Married 0.0261 0.0116 0.026 High SES (4) 0.0261 0.0133 0.052 Average birth intervals 0.0043 0.0024 0.077

R-Sq = 17.6% R-Sq(adj) = 14.4%

Table 7.9 Multiple linear regression for mid-calf circumference (log 10), non-pregnant women (n=203)

121 Predictor Coef SE Coef P Age (log 10) 80.97 20.00 0.000 Meat 13.34 3.54 0.000 Midhigh SES (3) 21.98 8.17 0.008 Pregnancy morbidity -16.77 6.08 0.006 Birth morbidity 11.97 6.39 0.063 Betania 39.92 15.37 0.010 Pinales -26.04 14.14 0.067 Payabila -21.66 13.47 0.110 Coyoles -22.05 14.18 0.122 Profession employment -18.14 11.11 0.104

R-Sq = 25.7% R-Sq(adj) = 21.6%

Table 7.10 Multiple linear regression for sum of skinfolds, non-pregnant women (n=203)

Parity was not significantly associated with fat reserves; however, for two age groups, 35-39 (t = -1.90, p =.07) and 50 and older (t=-1.40, p =.18), there is a slightly negative trend in BMI with increasing parity (see Figures 7.1 and 7.2).

122 Scatterplot of B M I vs Parity age group = 35-39 60

I M 4B0

0 2 4 6 8 10 12 14 L ive bir ths

Figure 7.1 Scatterplot of BMI and parity for women age 35-39

Scatterplot of B M I vs Parity Age group = 50 and older 60

I M 4B0

0 2 4 6 8 10 12 14 L ive bir ths

Figure 7.2 Scatterplot of BMI and parity for women age 50 and older 123 Dietary intake in this population is clearly not calorie deficient. Women appear able to meet increased caloric demands of reproduction. However, a diet adequate in quantity may lack quality. Can women in Miskito communities also meet higher micronutrient requirements and maintain immune function despite high investments in reproduction? Hemoglobin is examined as an indicator of maternal health next, because it responds to both nutritional status and disease (Kent 1992).

7.2 Hemoglobin concentration Hemoglobin is found in red blood cells and is essential to transportation of oxygen from lungs to body tissues. Low concentration of hemoglobin in the blood leads to anemia. The World Health Organization defines anemia as hemoglobin levels below 12.0 g/dl in non-pregnant and 11.0 g/dl in pregnant women. The cut-off for anemia is lower to account for hemodilution during pregnancy (plasma volume expands faster than red blood cell mass increases). The mean decrease in hemoglobin concentration during pregnancy is 1 g/dl or less when iron deficiency and other causes of anemia are absent (Bonnar & Goldberg 1969; Brown & Dawson 1972). Micronutrient deficiencies (e.g., iron, folic acid), parasitic infections (malaria and hookworm), and hemoglobinopathies are the most common causes of anemia worldwide (Boccio and Iyengar 2003). Chronic disease and infections (e.g.,

Tuberculosis, HIV/AIDS) also interfere with hemoglobin concentration. Biological and demographic factors influence micronutrient requirements and susceptibility to infection and chronic disease. Socioeconomic factors may also exacerbate a woman’s risk for anemia by denying her access to adequate food resources and healthcare. Potential consequences of anemia are reduced work capacity, increased morbidity from infections, greater risk of death associated with pregnancy and childbirth, low birth weight and prematurity, and diminished learning ability 124 (Boccio and Iyengar 2003). From an evolutionary perspective, anemia influences maternal and infant survival and RS. Anemia contributes substantially to maternal morbidity and mortality risk (Chi et al. 1981; Llewellyn-Jones 1965; Sarin 1995). Anemia decreases a woman’s ability to withstand excessive blood loss during childbirth. It also increases risk of infection and fatigue, impairs thermoregulatory responses, and increases cardiovascular stress due to inadequate hemoglobin and low blood oxygen saturation (Alauddin 1986; Kandoi et al. 1981; Brock 1999). In a hospital-based sample from India, incidences of preterm labor, low birthweight, and perinatal mortality were higher among severely anemic mothers (Sarin 1995). Severe anemia was a contributing factor in 35% of maternal deaths. Similarly, Malhotra and colleagues (2002) documented associations between severe anemia and low birthweight, increased rates of labor induction, operative deliveries, and prolonged labor. The functional consequences of anemia hold relevance for Miskito women, given that for the 55 maternal deaths reported by community members the leading causes of death were severe antepartum and postpartum bleeding, obstructed/ prolonged labor and infection. Hemoglobin was assessed for 315 women. While 215 of the women participated in individual interviews, the other 100 came to free anemia screenings offered at the local health clinic. Less information regarding their socioeconomic status is available; however, to increase sample size and represent younger, lower parity, and pregnant women in the survey of anemia, they are included in this analysis. For all 315 women, hemoglobin, reproductive status, and age were recorded. One-way ANOVA tests were used to identify significant differences among means for groups of different ages, reproductive status, parity, and socioeconomic status. Levene’s test for equality of variance confirmed that variances in hemoglobin concentration for groups were not significantly different. Chi-square and likelihood ratio Chi-square tests were used to determine significant 125 differences in the prevalence of anemia (rather than overall hemoglobin concentration) between groups. Two multilinear regression models were created to explain variation in hemoglobin; one for all 315 women, and one for the subset of 215 women that also includes socioeconomic variables. The mean age of the women in the sample was 33.5 years (n=315). The average number of live births to women in the sample was 4.8. Hemoglobin values ranged from 5.7 to 15.9 g/dl with a mean value of 11.9 g/dl (s.d.= 1.64) (Table 7.11). Total prevalence of anemia was 42.5% with 32.7% of women mildly anemic (12.0 g/dl to 10.0 g/dl), 8.3% moderately anemic (9.9 g/dl to 7.0 g/dl), and 1.6% severely anemic (less than 7.0 g/dl) (Table 7.12). The ANOVA and chi square tests identified significant differences in hemoglobin and anemia prevalence respectively among groups of different ages, reproductive status, socioeconomic status, BMI, and community of residence. Table 7.13 and 7.14 show mean hemoglobin concentration, standard deviation, and percent anemic stratified by different biodemographic and socioeconomic categories.

Mean Median s.d. Age 33.5 31 13.13 Parity 4.8 4 3.18 Hb concentration 11.9 12 1.64

Table 7.11 Description of the sample for Hemoglobin

126 Table 7.12 Prevalence of mild, moderate, severe and total anemia

Table 7.13 Mean hemoglobin and anemia prevalence by age, reproductive status and parity (n=315) 127 Table 7.14 Mean hemoglobin and anemia prevalence by socioeconomic status, education, BMI, family planning, and meat consumption (n=215)

128 Stepwise multilinear regression was used to determine the best-fitting model to explain hemoglobin variation. Given the potential for correlations among the variables analyzed using ANOVA, multilinear regression allows assessment of the roles of multiple independent variables on hemoglobin (after removing highly correlated independent variables). ANOVA results informed the inclusion of variables in the regression analyses. Two analyses were run: one for all 315 women (reproductive status, age, parity only) and one for the 215 women who provided more information about their socioeconomic backgrounds. The model for all 315 women (Table 7.15) identified positive relationships among hemoglobin and the 30-34 age cohort and zero parity. Pregnancy, the 14-19 age cohort, and current lactation are negatively associated with hemoglobin. The linear regression analysis for the 215 women (see Table 7.15) incorporated social, economic, and biological variables that were available for participants who participated in individual interviews. The sample for this model includes fewer pregnant women (n=13) and only seven women age 15-19. BMI, living in the villages of Cocobila, Ibans, or Nueva Jerusalén, and greater meat consumption were positively associated with hemoglobin. Low socioeconomic status, current pregnancy, and sterilization were negatively related to hemoglobin.

Predictor Coef SE Coef P Cum R2 Pregnancy -1.622 0.234 0.000 14.5% Age 30-34 0.539 0.237 0.024 16.1% Age 14-19 -0.722 0.357 0.044 16.6% Lactating -0.358 0.244 0.144 17.3% 0 parity 0.681 0.421 0.107 18.0%

R-Sq = 18.0% R-Sq(adj) = 16.6%

Table 7.15 Multilinear regression model for hemoglobin concentration by age, reproductive status, and parity (n=315) 129 Predictor Coef SE Coef P Cum R2 BMI (log) 319.60 103.60 0.002 6.5% Pregnancy -137.27 43.18 0.002 10.0% Low SES -52.14 22.15 0.020 12.2% Sterilization -56.04 21.53 0.010 14.9% N. Jerusalén 78.61 25.37 0.002 17.0% Ibans 66.06 29.53 0.026 18.4% Cocobila 68.51 26.38 0.010 20.9% Meat 21.84 11.96 0.069 22.2%

R-Sq = 22.2% R-Sq(adj) = 18.9%

Table 7.16 Multilinear regression model for hemoglobin (transformed, Hb 2.5) by reproductive status, BMI, SES, family planning, community of residence, meat consumption (n=215)

Statistical analysis suggests that young women (under age 20), pregnant women, and lactating women have significantly lower hemoglobin levels and higher rates of anemia than older and non-pregnant women. Young women are likely to enter their reproductive years with low nutrient reserves because of recent investment of nutrients in their own growth (Boccio and Iyengar 2003). Increased iron and folic acid requirements during pregnancy and lactation may also be stressful. Both folic acid and iron are mobilized from maternal reserves during pregnancy and lactation and must be replaced between reproductive events. Poor maternal iron stores may result from women’s inabilities to meet increased demands during pregnancy or from insufficient repletion after frequent reproductive cycles (King 2003). Results indicate that most women cannot meet the substantial increase in iron requirements during pregnancy by drawing on iron stores or increasing dietary intake and inevitably develop anemia. Iron requirements increase to meet demands of the fetus, placenta, and cord, expansion in maternal red blood cell mass, and normal losses from the gastrointestinal

130 tract, urinary tract, and skin. Approximately 800 to 1,000 mg of additional iron are required during pregnancy (Bothwell 1995). Blood losses at birth or during the postpartum period typically represent an additional 100-275 mg of iron. Iron needs peak during the third trimester at about 7 mg/day (Bothwell 1995). After pregnancy and delivery, iron deficiency may persist during lactation, though lactational amenorrhea may buffer against the loss of iron during menstruation. Iron requirements increase when lactating women begin to cycle again to a median of about 1.81 mg/day (Viteri 1994). Similarly, folate requirement nearly double during pregnancy, and malaria and hemoglobinopathies further increase folate needs. Decline in iron stores during pregnancy depends on total iron in the diet (including heme and non-heme iron), bioavailability of iron, and changes in iron absorption during pregnancy. Though mechanisms are poorly understood, iron absorption decreases in early pregnancy; this is followed by a three to fourfold increase beginning in mid-pregnancy (Hahn et al. 1951; Svanberg 1975; Svanberg et al., 1975). Increased absorption of iron during the second half of pregnancy does not appear sufficient to meet higher requirements and prevent the development of anemia (Hallberg 1988). Surprisingly parity groupings did not show significant differences in mean hemoglobin concentration and higher parity was not associated with higher rates of anemia. On the contrary, though means were not significantly different, women with 5-6 live births had a slightly higher mean hemoglobin than all of the lower parity groups. Despite the potential for life history tradeoffs between reproduction and maintenance, a larger number of reproductive events does not predict lower hemoglobin in this case. Perhaps some women experienced adequate recovery time between events (and in some cases after the complete cessation of reproduction) to replenish iron stores. Parity, however, is a crude indicator and a more comprehensive 131 look at changes in hemoglobin over birth intervals (e.g., during pregnancy, at birth, during lactation, during the recovery period) may clarify when women do and do not recover their iron stores. Rates of anemia are high across all parity groups (greater than 37%), and therefore, women of all parities are at risk of this health problem. In addition to reproduction, variation in genetic propensities to absorb iron and resist disease may explain hemoglobin variation (King 2003). Interethnic mixing with people of African descent may influence anemia prevalence in this population based on genetic (e.g., hemoglobinopathies) and social (e.g., discrimination/reduced access to resources based on skin color) effects. Without genetic data, however, the role of African admixture on hemoglobin concentration remains unclear. Results reported here support the hypothesis that low individual, household and/or community access to resources influences variation in hemoglobin and therefore, maternal health. All Miskito communities studied are resource-deprived, thus high rates of anemia were expected. Still, some communities and individual women within communities have less access to resources than others. Having fewer resources constrains women’s abilities to buffer their health and maintain hemoglobin levels. Residents of three communities, Ibans, Nueva Jerusalén, and Cocobila, had higher hemoglobin than those women living in other villages. One of two health centers in the area is in Nueva Jerusalén. The other is on the outskirts of Cocobila, in close proximity to the village of Ibans. In both Cocobila and Ibans, the majority of households have access to an improved water source and therefore may be exposed to fewer parasites in their drinking water. Previous development programs installed hand pumps in Ibans and a gas-powered water system in Cocobila. A substantial obstacle to maintaining health and well-being in Miskito villages is poverty. Women of lower SES have significantly lower hemoglobin and higher 132 rates of anemia than those of higher status. This not only influences women’s abilities to seek health care, but also their access to adequate and nutritious food. Dietary availability of heme and non-heme iron influences hemoglobin. Heme comes from animal sources (e.g., red meat, fish, poultry), has a higher absorption rate, and is less sensitive to enhancing or inhibiting factors or overall iron status (Hallberg 1981; Hallberg et al. 1989). Absorption of non-heme iron from plant sources depends on simultaneous intake of ascorbic acid or animal protein and is inhibited by tannins (e.g., coffee, tea) and soy proteins and chelated by phytates (e.g., legumes, bran, cereals) and calcium. Beef is not only an ideal source of iron, as with all meat, it also is highly desired food among the Miskito and other populations. Yet, most Miskito women do not eat beef on a regular basis due to high costs. Lack of heme in the diet likely interferes with abilities to meet iron requirements. Sharma et al. (2003) attributed high rates of anemia (96%) among pregnant women in Delhi to low rates of meat eating. In this analysis, meat consumption in the last 24 hours is positively associated with hemoglobin concentration (p = .069). This suggests that iron deficiency is partly responsible for the observed low hemoglobin levels. Food preparation practices may also influence micronutrient deficiencies. Most households use aluminum rather than iron cooking pots. Also, prolonged cooking and reheating food may interfere with folate absorption (Viteri 1994). For example, beans generally cook on the stove all day long and are served for each meal until the supply is completely consumed by the household.

7.3 Systolic and diastolic blood pressure Blood pressure is influenced by lifestyle, behavioral, environmental and genetic factors (Beilin et al. 1999). Stress associated with acculturation,

133 modernization, and lack of social support has also been linked to higher levels of blood pressure (Dressler et al 1986; Dressler and Bindon 1997; Bindon et al. 1997). Excess body fat (which may increase plasma volume and cardiac output), physical activity, and dietary intake of salt and potassium may also be related to hypertension (Sutur et al. 2002; Stamler 1991; Beilin et al. 1999). These factors interact in complex ways; for example genes, obesity, low potassium and calcium intake may influence salt sensitivity among individuals (Suter et al. 2002). The mean systolic blood pressure in this sample was 119.7 mmHg (s.d. = 16.5), with a range of 90-190 mmHg (Table 7.17). Diastolic blood pressure averaged 73.5 (s.d. = 11.04) and ranged from 47-117 mmHg (Table 7.17). Systolic blood pressure for the majority of women (56.9%) was in the optimal range (less than 120 mmHg), 25.2% were in the normal range (120-129 mmHg), 7.9% had high readings (130-139 mmHg), and the measures for 10.2% are classified as hypertension (140 mmHg or higher) (Table 7.18). For diastolic blood pressure, 75.7% of women were in the optimal range (less than 80 mmHg), 12.8% were normal (80-84 mmHg), 4.1% had high readings (85-89 mmHg), and 7.3% of women were hypertensive (90 mmHg or higher) (Table 7.19).

Blood pressure Mean s.d. Range Systolic 119.72 16.45 90-190 Diastolic 73.54 11.04 47-117

Table 7.17 Systolic and diastolic blood pressure levels

134 Systolic blood pressure n Percent <120 124 56.9% 120-129 55 25.2% 130-139 17 7.9% 140+ 22 10.2%

Table 7.18 Classifications of systolic blood pressure

Diastolic blood pressure n Percent <80 165 75.7% 80-84 28 12.8% 85-89 9 4.1% 90+ 16 7.3%

Table 7.19 Classifications of diastolic blood pressure

Populations Systolic Diastolic Honduras 123.0 - Miskito 119.7 73.5 Yanomami* 90.6 56.5 Xingu* 96.2 59.2 Papua New Guinea* 106.4 61.0 Kenya* 107.9 64.7

* Data from INTERSALT populations (Carvalho et al. 1989)

Table 7.20 Comparison of women’s mean blood pressure in different populations

The mean blood pressure for women in Miskito communities is lower than the

Honduran national average, 123.0 mmHg (WHO 2007), but higher than four isolated

135 populations included in the INTERSALT study (Carvalho et al. 1989) (Table 7.20). The high number of women with optimal blood pressure levels is surprising given the prevalence of overweight and obesity in the population; however, body fat alone does not determine blood pressure. Dietary intake of potassium was negatively associated with blood pressure in multiple studies (Suter et al. 2002; Sacks et al. 1998). Possible mechanisms include potassium’s influence on baroreceptor activity, vasodilatory functions, catecholamine metabolism, and the excretion of sodium (Suter et al. 2002). Bananas and plantains are eaten on a daily basis by women in Miskito communities. High intake of potassium-rich foods like bananas and plantains may buffer women against hypertension. Stepwise linear regression analysis was used to analyze relationships among blood pressure (systolic and diastolic) and biological, demographic, and socioeconomic factors (Table 7.21 and Table 7.22). Individual age and average age of household members were both positively associated with systolic blood pressure. Earning substantial wages (e.g., teaching, nursing, running a local store) was negatively associated with systolic blood pressure. Thus, women with more economic independence had lower systolic blood pressure. The model for diastolic blood pressure includes these same three variables in addition to BMI, having experienced proportionally more morbidity during pregnancies, having a mother who is alive, and a father who is alive were all positively associated with diastolic blood pressure. Membership in a community organization, having a spouse that works in agriculture (rather than at sea), waist circumference, and living near maternal relatives (the cultural ideal residence pattern) are negatively related to diastolic blood pressure reading. Figures 7.3 and 7.4 show scatterplots of age and blood pressure, which are positively associated for both systolic and diastolic measures.

136 Predictor Coef SE Coef P Age 0.56 0.10 0.000 Average household age 0.34 0.15 0.000 Earns substantial wages -6.38 3.61 0.079

R-Sq = 25.8% R-Sq(adj) = 24.8%

Table 7.21 Multiple linear regression model for systolic blood pressure (n=218)

Predictor Coef SE Coef P Average household age 0.28 0.10 0.008 Membership in organization -3.92 1.47 0.008 Age (log10) 27.59 6.88 0.000 Waist circumference -0.30 0.13 0.019 Spouse works in Agriculture -3.80 1.64 0.021 Earns substantial wages -5.19 2.64 0.051 Mother is alive 2.71 1.73 0.119 Lives near maternal relatives -2.48 1.43 0.085 BMI (log) 52.38 17.90 0.004 Pregnancy morbidity 3.48 2.50 0.013 Father is alive 3.06 1.66 0.067

R-Sq = 23.4% R-Sq(adj) = 19.2%

Table 7.22 Multiple linear regression model for diastolic blood pressure (n=218)

137 Figure 7.3 Scatterplot of age and systolic blood pressure

Figure 7.4 Scatterplot of age and diastolic blood pressure

138 Age, socioeconomic, and lifestyle factors contribute significantly to explaining variation in indicators of health for women in these Miskito communities. Parity was not significantly associated with body habitus, hemoglobin concentration, or blood pressure. However, women’s negative experiences during reproductive events, specifically morbidity during pregnancy, were related to lower fat reserves and higher diastolic blood pressure. Likewise, current investment in reproduction was negatively associated with hemoglobin. Pregnant and lactating women had lower hemoglobin concentrations and higher rates of anemia.

139 CHAPTER 8

MATERNAL MORTALITY IN COASTAL COMMUNITIES ALONG THE IBANS LAGOON

8.1 Introduction This chapter discusses the proximate, intermediate, and ultimate causes of maternal death in Honduran Miskito communities. Data collected during focus groups, individual interviews with family members of deceased women and local midwives, nurses, and doctors, and observations of events in the communities provide the basis for descriptive statistics and qualitative analysis. Community members identified the problems pregnant women face in this region and emphasized how poverty, lack of adequate health care, and gender inequality contribute to maternal mortality. Participants stressed the importance of social threats – from economic insecurity and sociopolitical marginalization to witchcraft and sorcery – to women’s health. Identifying these complex social risks aids in developing holistic explanations for variation in health outcomes and identifies appropriate avenues for decreasing reproductive vulnerability. Large-scale political and economic forces perpetuate this public health problem. Therefore, preventing poor maternal health outcomes and treating complications will require large-scale efforts addressing structural inequities that place women at risk of maternal morbidity and mortality.

140 8.2 Summary statistics for maternal deaths Women reported 55 maternal deaths that occurred within the past 53 years. Of these, one death (1.8%) occurred in the 1950s, 3 in the 1960s (5.5%), 6 in the 1970s (10.9%), 12 in the 1980s (21.8%), 18 in the 1990s (32.7%) and 15 between 2000 and 2005 (27.3%). This does not necessarily mean that maternal deaths have increased over time. Family members are less likely to remember or be alive to report a maternal death that occurred in the 1950s or 1960s. However, the fact that 15 women died during the period from 2000 to 2005 in an area with a total population of approximately 5,000 people demonstrates that maternal mortality is a pressing public health problem in these communities. Hemorrhage, including severe antepartum and postpartum bleeding, was the immediate medical cause of 24 deaths (44.4%) (Figure 8.1) . Family members often cited common risk factors for hemorrhage during verbal autopsies. Most often they reported placenta previa, retained placenta, placental abruption, multiple gestation, a large baby, multiparity, and labor augmented with pitocin. Obstructed/prolonged labor was reported as the cause of thirteen deaths (24%). Reports of these deaths most often included malposition of the fetus, multiple gestation, and large baby/ cephalopelvic disproportion as explanations for the long duration of labor. Sepsis accounted for six deaths (11.1%) and hypertensive disorders (eclampsia) for four

(7.4%). One death occurred due to complications related to an ectopic pregnancy and another as a result of embolism. Five (9.1%) indirect obstetric deaths (e.g., deaths due to conditions that may have been aggravated by pregnancy, but did not develop directly due to pregnancy) were reported including two cases of hepatitis, one case of tuberculosis, one case of hemorrhagic fever and one maternal death caused by a motorcycle accident that led to severe bleeding due to trauma. No one identified induced abortion as a cause of death but there were other accounts during focus group 141 discussions and individual interviews of women becoming ill after ingesting herbs as well as committing suicide during unwanted pregnancies.

Figure 8.1 Reported causes of maternal death

Previous research (see Maine 1981, Maine and McCarthy 1992) has demonstrated that the youngest and oldest women of reproductive age have the highest risks for maternal mortality. Among the deaths reported in this study, the majority of women who died belonged to the youngest age cohort. Thirteen (23.6%) of the women were between 15-19 years old, 10 (18.2%) were age 20 – 24, 14 (25.5%) were 25-29, 9 (16.4%) were age 30-34, 7 (12.7%) were 35-39, and 2 (3.6%) were age 40-44 (Figure 8.2). The majority of women (67.3%) died before age 30, which corresponds with the age cohorts during which births are most numerous and closely spaced for women in this population. The specific causes of death did not vary significantly by age (Kruskal Wallis test; p=0.9). 142 Figure 8.2 Maternal deaths by age cohorts

Information regarding parity was collected. Family members reported that 13 women (23.6%) had never experienced a live birth prior to the reproductive event that culminated in their deaths, nine had given birth to one child previously (16.4%), seven (12.7%) had two previous live births, six (10.9%) had experienced three previous live births, five (9.1%) had four previous live births, five (9.1%) had five previous live births, six (10.9%) had six previous births, three (5.5%) had seven previous births, and one (1.8%) had eight previous live births (Figure 8.3). As with age, the expected relationship between parity and maternal mortality is a J/U-shaped curve (McCarthy and Maine 1992). As predicted, in this sample primiparas died at higher proportions than multiparas. The risk of mortality typically decreases significantly after a woman successfully gives birth once; however, in this case the percentage of women who died despite experiencing one live birth remains relatively high.

143 Figure 8.3 Maternal deaths by the number of previous live births

In 31.5% of the cases of maternal mortality, births were attended by family members, while midwives and/or private nurses in the communities attended 38.9% of such births. Doctors attended 29.6% of the births. These numbers may be deceiving given that women and their family members often did not seek care from a midwife, nurse, or doctor until after complications arose. In particular, taking women to a hospital to receive care from a doctor was often the last resort. The time delay associated with seeking a doctor after a family member, midwife, or nurse realized they could not adequately handle a problem was often cited as the reason medical interventions failed. In eight of the 55 cases women died either waiting for transportation to a hospital in a canoe or airplane, or in route. The majority of women (39) did receive some form of prenatal care from a health center, midwife, or private 144 nurse but 15 (27.3%) did not owing to embarrassment, lack of resources or access, or the belief that prenatal care was not necessary based on a personal history of no complications during previous births. Five of the women who died were pregnant with twins. Just under half of the pregnancies (46.7%) resulted in live births but of the 28 live births, 17 later died before reaching their first birthday (seven within hours of their mothers’ deaths). There were 37 perinatal deaths (including fetal deaths and deaths during the first week of life), two more children died during the first month of life, and seven more died before age 1. Of the 55 pregnancies (five of which were multiple gestations), only eleven children (20%) were alive at the time of this study. Orphaned children’s vulnerability is produced by both biological and social factors. Women are primary caregivers in Miskito society; hence, surviving children rarely remained with their biological fathers. Instead other family members adopted them, typically their maternal grandmothers. While less than half of these children survived the complications during pregnancy/birth their mothers experienced, even fewer received adequate nutrition and protection from environmental stressors after their mothers’ deaths. Relatives who took in babies and other surviving children orphaned by maternal mortality often discussed their difficulties supporting them and stressed the need for resources to help them raise these children. For instance, though typically available in local shops, infant formula is very expensive (one small container costs the equivalent of a days wage for agricultural labor) and households often lack access to safe, clean water to mix with the formula. Adoptive families often resorted to using rice water as a cheaper, albeit much less nutritious alternative. Knowing the immediate medical causes of death contributes little to an understanding of why women are at risk of dying due to pregnancy-related complications. Why is it that women in these coastal Miskito communities are dying 145 if maternal mortality is largely preventable? To answer this question an examination of intermediate and more distant factors that lead to complications or the failure to treat complications is necessary. Local women, men, midwives, nurses, and doctors were asked to identify major causes of maternal mortality during focus groups and individual interviews. Three key issues related to maternal deaths emerged through analysis of community members’ perceptions – poverty, gender inequality, and sorcery or witchcraft. The relevance of these issues to maternal mortality is discussed below. Family members’ reports of specific maternal deaths help to illustrate the importance of larger economic and cultural factors influencing maternal health.

8.3 Lack of adequate economic and healthcare resources Pregnancy creates new physiological demands and exacerbates previously existing infectious and non-infectious diseases. A woman’s health status influences pregnancy outcome and her ability to survive after a complication arises. In the sample, hepatitis and tuberculosis as well as anemia were reported as indirect causes of maternal mortality. Adequate treatment for these diseases is only sporadically available at local health centers. Likewise, these conditions are often not identified in the first place owing to a lack of laboratory testing facilities. The failure of the Honduran government to provide sufficient medicine and supplies to health centers translates to lower rates of use of facilities by the population. Women choose to stay home instead of spending the whole day waiting in line or spending scarce monetary resources on a consultation when they know the center has been out of medicine or prenatal vitamins for over a month. Limited hours of operation and the perceived unwillingness of doctors or nurses to help during emergencies outside of these hours also limit health-seeking behavior. Case study #1: Emelina, age 32, was bleeding after delivering a healthy baby. Early on during labor, her family had sent for a doctor and nurses who worked at the 146 health center to attend her birth but they refused to come. The family found a midwife to help instead. The midwife attending the birth was unable to deliver the placenta and so the family sent for a nurse again. By the time she arrived, Emelina was unconscious. Though the nurse was able to remove the placenta Emelina died soon after (even before a second nurse arrived to help). Women usually turn to local midwives (parteras) or nurses with private practices to attend their births and help if complications occur. Nurses and traditional birth attendants have received varying levels of biomedical training. Midwives in particular often voiced their concerns over the lack of training seminars and general support offered to them by governmental agencies in recent years. Ideally the health centers provide them with gloves, gauze, iodine and alcohol as needed. However, short supply of such items sometimes precludes this. To date, non-governmental organizations have not stepped in to fill these voids adequately. While midwives feel like they receive less governmental assistance than in the past they also believe that they are more likely to be punished (e.g., sent to prison) if a woman dies under their care. Now maternal deaths that occur in these communities are reported by health center personnel to the public health department which then sends representatives to investigate the death. Some midwives and private nurses have received threats that efforts will be made to prevent them from attending births or providing any other health care services in the future if additional problems are reported. This in turn leads them to refuse to provide services to women they believe have a high risk of experiencing complications during birth (for instance, women under age 15), which further decreases health care options available to pregnant women. While the two local health centers prove inadequate for meeting health needs, people generally speak positively about the treatment available at the private clinic 147 located in Palacios, the private hospital in Ahuas, and the public hospital in Puerto Lempira. Unfortunately the distance and cost of transportation to these facilities represent barriers to use, especially during emergencies. Most families lack the resources to transport women to hospitals to give birth even if doctors, nurses, or parteras recommend they do so based on previous problems or assessments of current risk of complications. If an emergency occurs women cannot be transported unless it is during daylight hours and the family can collect enough money to charter a small airplane (which typically costs $275 or more) or a canoe with an outboard motor. Raising enough money and then finding transportation is especially difficult during the annual moratorium (veda) on lobster harvesting. Local economies almost shut down without the movement of money supplied by the wages men earn working at sea. Very few trips by car or motorized canoe are available during this time. Most people cannot afford passage so entrepreneurs cannot earn profits running collective transportation services. Case study #2: Yolanda, age 18, was pregnant with twins and went into labor almost a month early. The birth failed to progress and she began to hemorrhage. Despite giving her two injections of pitocin, a private nurse was unsuccessful at delivering the babies or stopping the bleeding. By the time Yolanda’s family had gathered the money to charter a plane to the hospital in Ahuas and arranged for transport, too much time had passed. Yolanda died at the airstrip in Belen, waiting for the plane to arrive. Family members observed the twins moving inside of her for an hour before they too, died. Poverty is the underlying cause of most maternal deaths in the region. In the words of many participants “if a woman doesn’t have money, she just has to die”. This not only relates to her ability to seek health care but also to her access to adequate, nutritious food and safe, clean water. Poor nutrition can lead to negative 148 energy balance thereby putting women at risk for infection due to impaired immune function as well as nutritional diseases. Women often described poor health, especially anemia, as the result of eating too little meat (upan). Meat is both the most culturally important and the most expensive component of the Miskito diet. The introduction of pathogens by drinking contaminated water leads to infectious and parasitic disease. The stress associated with economic insecurity may further magnify health problems. Poverty-induced suffering is often long-term with episodes of acute hardship (e.g., untreated health complications) that represent immediate threats to women’s lives.

8.4 Gender inequality Women tend to be more susceptible to poverty than men in these coastal communities because they lack employment opportunities, and therefore, economic autonomy. Although they may be able to find work washing clothes or cooking or selling baked goods these jobs tend to be low in pay and temporary (though the exceptions would be jobs in nursing and teaching). Therefore, women typically rely on wages men earn working at sea to meet household needs. This economic dependence on men is problematic for women when their spouses choose to spend the money they earn on alcohol, drugs, luxury items for themselves, or other women. Women often reported stressful conflicts with their spouses over irresponsible spending of money. These fights can become violent at times, particularly when drugs and alcohol are involved. During maternal mortality interviews family members occasionally mentioned neglect or physical abuse by the woman’s spouse prior to her death. Case study #3: Ledetenia, age 26, gave birth in a cayuco (small canoe) with only her spouse present. The child was stillborn and she suffered uterine prolapse. As time went on her husband prevented her from getting help despite her increasing 149 fever. She was able to get word to her brother and sister-in-law who proceeded to try to convince her spouse to take her to the hospital. He refused, arguing that he did not have the money to do so. Ledetenia’s family had a strained relationship with her husband, as they believed that he had been physically abusive to his wife throughout their union. She died three weeks after giving birth. There were several cases in which spouses prevented women from seeking prenatal care or going to a hospital after complications arose by withholding money or permission. Some men believed the expense of sending a woman to a hospital was too high and underestimated her risk of death. Case study #4: Juliana, age 34, had been advised by the doctor at the health center to go to the hospital in Ahuas because she had already experienced six previous births and was currently suffering from severely swollen veins in her legs. Her spouse disagreed, believing she was just as capable of giving birth at home as she was in the past. He said that the trip to the hospital would be too expensive. Despite attempts to save her life by two midwives and a nurse, Juliana died twenty minutes after labor while her husband was at sea diving. Some spouses restricted women’s visits to male doctors because they wanted to prevent another man from seeing their wives without clothing. Many men do not permit women to use contraception or become sterilized due to fears that women’s abilities to prevent pregnancy make it easier for them to have and hide relationships with other men. Thus, women not only suffer from economic dependence but also a lack of autonomy with regard to sexual and reproductive decision-making.

8.5 Witchcraft and sorcery In 12 of the 55 cases of maternal death at least one family member cited witchcraft or sorcery as the ultimate cause of death (almost 22%). The proximate 150 causes of these deaths appear to be common biological complications like severe bleeding, eclampsia, and prolonged/obstructed labor. However, according to members of Miskito communities, the ultimate cause of these complications may actually be witchcraft or sorcery. As with physiological causes of complications, sorcery and witchcraft represent health emergencies that demand swift action by Miskito herbalists (curanderos) to combat dangerous social causes of illness. Because the symptoms of sorcery and witchcraft often look identical to biomedical complications, determining the actual cause of the problem remains difficult, and women may not receive Miskito medicine in time to save their lives. When death was particularly unexpected (i.e. the complications did not appear to be severe) or sudden, family members often interpreted the cause to be sorcery. Family members most often cited jealousy, envy, and revenge as the reasons sorcery or witchcraft were used against pregnant women. Women who were having relationships with married men or wives who were disliked by their spouse’s relatives were considered to be likely victims of poison and trick. Women who had wronged no one in particular, but ‘lived well’ (i.e., were materially better of than their neighbors) were at risk of sorcery as well. Economic change in the region has benefited a few community members, particularly those lucky enough to obtain (or have a family member obtain) stable, relatively well-paid employment, while most live in poverty without the shelter, food, and material goods they need and desire. Even a poor woman experiencing pregnancy may evoke feelings of jealousy among childless women or other women competing for the attention and resources of the baby’s father. Case study #5: Olivia, age 18, died during the eighth month of her first pregnancy. She had a severe headache and stomachache and experienced vomiting, dizziness, and later convulsions (consistent with eclampsia). Her mother, sister, and 151 a midwife attempted to care for her, as her family lacked the money necessary to transport her to a hospital. They were getting ready to take her to the health center in Cocobila when she died. A widespread belief among community members is that Olivia’s former lover, Carlos, used Trick to kill her because he was angry and jealous that she was living with another man and was pregnant with his child. Case study #6: Two years later Carlos’ fifteen year old sister, Miriam, died of hemorrhage during her ninth month of pregnancy while in a canoe (cayuco) on the way to the health clinic in Palacios. Her family believes that the cause of her death was also Trick poison representing revenge on the part of Olivia’s family. Because Carlos was responsible for her death, as retribution, his sister, Miriam, also had to die. The fact that people believe pregnancy complications often have social causes contradicts public health perspectives which tend to focus on biomedical etiologies alone. Cultural understandings and explanations of maternal death hold implications for prevention and treatment of pregnancy complications. If the cause of illness is witchcraft or sorcery, people view biomedical treatment as virtually useless in preventing death. The only cure for poison or trick is Miskito medicine (e.g., herbs). Community members and midwives believe that the number and quality of doctors, nurses, and health facilities bear no impact on the incidence of these illnesses (more than one-fifth of the sample in this case). Likewise, attending the local health center for prenatal care offers no protection against sorcery. On the contrary, it may bring more public attention to women’s pregnancies, thereby increasing jealousy and envy among others. Though they may report the same symptoms, community members do not always agree on the ultimate cause of each maternal death. Charges of witchcraft and sorcery are often discussed and disputed. Maternal deaths, in general, are surrounded by controversy as family members, neighbors, health center employees, and midwives 152 evaluate each person’s actions during the pregnancy and crisis. Individual actors stand to benefit or suffer depending on the final consensus regarding the cause of death. If people generally agree that the ultimate cause of death was sorcery, only those accused of poison or trick may face consequences; thereby alleviating the blame for unsuccessful attempts to save the woman’s life by nurses, midwives, or family members attending the birth. The following case study illustrates how community members began (the death occurred just over a month before fieldwork ended) to sort through the events that occurred and eventually led to the death of a young woman. Case study #7: Attended by a private nurse and her grandmother, sixteen year old Justina gave birth to a healthy baby weighing nine pounds. Soon after delivery of the baby, she began to bleed severely, her blood pressure dropped, and she began to shake. She died within a couple of hours after birth. People began to suspect her in- laws of using poison to cause her death. Her mother-in-law in particular did not like her and had reportedly told Justina that she hoped she would die during childbirth. Her grandmother said that soon after delivery Justina began to say strange things about making sure her baby was well taken care of if something happened to her, just before complications began. She gave Justina herbs, but believes the treatment came too late. Other community members explained the death in biomedical terms. They believed that the private nurse had given the young women too many injections of pitocin and never delivered the placenta. People cited the young woman’s swollen stomach after death as evidence of this theory. Though her grandmother reported burying the placenta immediately after delivery, no one witnessed her do this. They began to accuse the private nurse of telling people to keep quiet about what happened to protect her reputation, and therefore, her ability to continue her healthcare practice. If community members believed that the death occurred as a result of sorcery, rather than medical malpractice this would be in the nurse’s best interest (especially when 153 members of the health department came to investigate the maternal death). However, if the cause of death was a natural complication, inappropriately handled by a private nurse this would exonerate Justina’s in-laws from any involvement in her death. Whether Justina’s relatives used poison or not, a potentially important question remained unasked. Did the young woman’s belief that she was a victim of sorcery play a role in her death? If beliefs can be powerful enough to heal, they may also be powerful enough to cause sickness and death. In other words, negative expectations can result in negative effects on health. Hahn (1997:607) defines this nocebo effect as “the causation of sickness or death by expectations of sickness or death.” Hahn and Kleinman (1983:3) describe the impact of belief on health as an “interaction between culture and physiology mediated by central nervous system processing of symbolic perception in experience.” The mechanisms that translate cultural beliefs into physiological outcomes require more investigation, though a variety of immunological, neuroendocrine, and autonomic nervous system effects have been suggested (see Hahn and Kleinman1983; Dein 2003). Societal perceptions that sorcery and witchcraft are major causes of maternal mortality influence individual women’s beliefs that they may become victims of poison or trick. Their expectations that sorcery or witchcraft will lead to severe health consequences may contribute to their own actual experiences of illness and death. Larger political and economic forces contribute to changing conditions in these communities, including increasing economic insecurity, wider income disparities and social conflicts, which in turn influence cultural perceptions that sorcery and witchcraft are responsible for many deaths. Other authors have also drawn attention to how international development efforts and national economic policies can create dangerous social environments at the local level. For example, 154 Pfeiffer (2002) argues that neoliberal restructuring in Mozambique has led to increasing inequality, which in turn has influenced social cohesion. Growing competition, violence (or at least the fear of violence), and conflicts within families have coincided with greater fears of witchcraft and sorcery. Likewise, Eves (2000) focuses on widespread evidence that social change brought about by modernization and market integration is associated with heightened claims of witchcraft and sorcery in Melanesia. However, he points out that local responses to change are varied and context-dependent. In the case of the Miskito people, witchcraft and sorcery do not represent new responses to contemporary changes. Instead, these personalistic etiologies have historically played important roles in the production of poor health. However, community members report increasing incidences of poison and trick as social conditions deteriorate and people develop motives to “do bad things” to others. As women increasingly worry about becoming victims of sorcery and witchcraft, their beliefs and anxiety may potentially influence their abilities to withstand complications that arise.

8.6 Conclusion In coastal Miskito communities located along the Ibans lagoon poverty, women’s lack of autonomy and insufficient access to health care interact in complex ways to produce compromised health and maternal mortality. At the national level, inadequate political and financial commitments to maternal health contribute to poor obstetric outcomes. Members of these communities feel abandoned and ignored by the Honduran government which cites limited resources for its inability to expand and improve the availability of healthcare services. Participants cited a number of structural barriers to healthcare access including distance to facilities, the high cost of transportation and services, housing, and food for women and their families who 155 travel to hospitals for care, lack of specific services and supplies (from prenatal vitamins to laboratory testing for malaria, anemia, etc.) at health centers, and inappropriate and disrespectful treatment by health service providers. Maternal health initiatives are not high among the country’s funding priorities. Though isolation and lack of infrastructure on the Mosquito Coast pose challenges to improving health, they may also be used by the government to excuse lack of attention. Real commitments to tear down structural barriers of access to healthcare are required. Given the health department’s focus on encouraging high- risk women to travel to hospitals to give birth (rather than training local midwives to treat complications that arise), services to transport women to hospitals in efficient and cost-effective manners are needed. Likewise, improving access to emergency obstetric care is often cited as key to decreasing maternal mortality in developing countries (Fortney 2001; Razzak and Kellermann 2002; Paxton et al. 2005). In this case, there is also a need to improve emergency transport to hospitals for women experiencing complications while giving birth at home. Only then will they have opportunities for potentially life-saving obstetric care. In addition to lack of economic resources and infrastructure, there are other important reasons why the majority of women give birth at home and transport to biomedical facilities is delayed during obstetric emergencies.

Perceptions of risk, along with attempts to balance the costs and benefits of different birth management strategies influence decisions women and their families make regarding healthcare. Despite the fact that community members recognize maternal mortality as a threat, there are many more ‘near misses’ (where women survive despite complications) than maternal deaths. Women prefer to give birth in the comfort of their own home with family members attending them instead of the unfamiliar environment of a hospital, surrounded by strangers who may treat them 156 poorly. Likewise, going to a hospital means that women and their families have decided that biomedical treatment is the best option given their beliefs about the type of risk an individual woman faces or the cause of a complication. By leaving her home and community, a woman may have to give up what Chapman (2003:364) calls the simultaneous “layering of protection and treatment from different sources”. Many midwives have both biomedical and herbal knowledge and therefore, can treat naturally occurring complications as well as those caused by witchcraft or sorcery. Likewise, a woman might receive care from a private nurse at the same time a curandero administers herbal treatments for poison or trick. By giving birth at home, a woman can better draw upon different types of treatment because her family can ask midwives, nurses, or other traditional healers in the community, who they know personally and trust, to come help if complications arise during pregnancy, birth or after birth. Berry (2006) similarly found that indigenous Guatemalan women favored giving birth at home over preventative admission to a healthcare facility and therefore typically waited until a complication arose to be referred to a hospital. The effectiveness of improving emergency obstetric care among women on the Mosquito Coast depends not only on their families’ abilities to afford it, but also the social risks it poses, including perceptions of security and comfort, and the extent to which it interferes with other types of treatment.

Biological and demographic characteristics place certain individuals at higher risk of poor maternal health. However, social risks – poverty, patriarchy, and the conflicts that increase vulnerability to sorcery and witchcraft – are of greater significance in this case. There is no simple way to prevent maternal deaths in the region because this public health problem is rooted in social inequality and economic insecurity. Ultimately, interventions to improve maternal health need to focus on larger social, political and economic factors that serve to marginalize women in communities. 157 CHAPTER 9

DISCUSSION AND CONCLUSIONS

9.1 High investment in reproduction As expected, high fertility characterizes Miskito communities. Women begin investing in reproduction at early ages, on average experiencing menarche between ages 13 and 14, first marriage at age 16, and first pregnancy at 17 years. The pace of childbearing is most rapid at ages 20-29 and begins to taper off after age 30. By the end of their reproductive careers women have experienced 7.7 live births on average. The fertility of older women who have completed their reproductive years is slightly higher (mean = 8.2 live births) than the current total fertility rate, suggesting that fertility rates are declining. In addition to meeting the energetic demands of just under eight pregnancies, women also breastfeed each infant for 15 months on average. Average fertility rates are high; however, individual women show substantial variation in the number of offspring they produce. Women age 45 and older have experienced three to fourteen live births. Over 68% of the variation in fertility among women in this sample is explained by maternal age, age at first pregnancy, average breastfeeding duration, birth control use, marriage, and SES. Women voice preferences for large families based on the social, economic, and psychological benefits of children. However, their abilities to support as many children as they would like to have are increasingly limited by changing economic circumstances. Likewise, women believe that childbearing itself can be costly in terms of maternal health.

158 9.2 Population measures of women’s health Data on morbidity experienced during pregnancy, birth, and the postpartum period were collected to examine the potential costs of reproduction on maternal well-being. Women reported health problems during 23.2% of pregnancies. The most common health issues were pain (particularly lower abdominal pain), severe pregnancy sickness, and swelling of the feet, hands, or veins. Complications occurred in 26.5% of births. Prolonged/obstructed labor, retained placenta, and severe bleeding were most common. Women experienced morbidity during the postpartum period in 24.3% of cases. Abdominal pain, severe bleeding, and fever were most often reported. In one out of four or five pregnancies, births, and postpartum periods women experienced complications that impacted their health. This seemingly high rate of morbidity is most likely an underestimate of maternal morbidity given that women were recalling problems from past reproductive events. In some cases, complications that arise during pregnancy, birth, and the puerperium end in maternal death. Reports of maternal deaths by women in Miskito communities suggest that high maternal mortality for the department of Gracias a Dios continues today as it did in the 1990s (878 maternal deaths per 100,000 live births). Women reported 55 maternal deaths, 15 of which had occurred in the past six years (from 2000 to 2005). Mothers continue to die of preventable causes such as hemorrhage, obstructed/prolonged labor, and infection. When mothers die, their fetuses and newborns are also less likely to survive. Just under half of the reproductive events that ended in maternal death resulted in a live birth; however, by the time of this study, only 20% of the children who survived birth were still alive. Of the 28 live births, 60.7% died before their first birthday. In comparison, among surviving women, only 5.3% of live born children died before reaching age 1. The infant and under age five mortality rate for surviving women were 54.7 and 74.5 deaths per 1,000 live births respectively. 159 Community members commonly state that maternal mortality is a significant problem. They maintain that the ultimate causes of maternal mortality are poverty and lack of sustained access to healthcare, gender inequality, and witchcraft/sorcery. Family members, midwives and/or private nurses attended 70.4% of births to women who died. Among surviving women, 80.6% of births were attended by midwives and/ or private nurses or family members with no healthcare training. Doctors attended 29.6% of births that ended in maternal death and only 19.4% of births to surviving women. In both cases, women generally did not seek care from a doctor (or in some cases nurses) until after complications arose. In addition to information regarding maternal morbidity and mortality, body composition, hemoglobin concentration, and blood pressure were measured to assess current health status of Miskito women. Analysis of body mass index (BMI) determined that rates of overweight and obesity are high. Only two women have BMIs under 18.5 kg/m2 (considered underweight), while 72.5% were overweight or obese. Likewise, using a waist circumference measure of 88 cm or more as an indicator of fatness, 63.5% of women are considered obese. These results indicate that Miskito women are at high risk of chronic diseases associated with obesity, including diabetes, hypertension, and cardiovascular disease. Despite the high energetic demands of repeated pregnancies and lactation, almost all women sampled were considered of normal weight, overweight, or obese. While diets are adequate in terms of calories, women may be suffering from micronutrient deficiencies. Total prevalence of anemia was 42.5% with 32.7% of women mildly anemic (12.0 g/dl to 10.0 g/dl), 8.3% moderately anemic (9.9 g/dl to 7.0 g/dl), and 1.6% severely anemic (less than 7.0 g/dl). The high prevalence of anemia among adult women suggests that dietary iron deficiency and/or parasitic infection (e.g., hookworm, malaria) influence health status. Women report anemia as a common local 160 health problem, but often lack resources to prevent and treat its causes. Poorly-supplied health centers are unable to identify infections or offer supplements or medications to anemic women. Despite high rates of overweight and obesity, most women’s blood pressure levels are in the optimal range (less than120/80 mmHg). The prevalence of high blood pressure and hypertension was 18.1% for systolic blood pressure and 11.4% for diastolic blood pressure. Like anemia, women believe that both high and low blood pressure levels are responsible for health problems experienced by non-pregnant and pregnant women. Hypertensive disorders accounted for 5% of complications women experienced during pregnancy and 4% during birth. Likewise, family members reported that symptoms associated with hypertensive disorders caused four of 55 maternal deaths.

9.3 Risk factors for poor health outcomes Age Age is positively associated with six health measures, BMI, arm circumference, waist circumference, sum of skinfolds, systolic and diastolic blood pressure. Both fat reserves and blood pressure levels increase with age; therefore, older women are potentially at higher risk of chronic diseases associated with obesity, including hypertension. Women aged 30-34 years have higher hemoglobin, while those aged 14-19 have lower levels. Young women, on average, also have lower body fat reserves. Rates of anemia are highest among young women.

Meat consumption and body composition Meat consumption was positively associated with BMI, arm circumference, waist circumference, sum of skinfolds, and hemoglobin concentration. Women with 161 more meat in their diets have greater fat reserves. Meat consumption potentially offers protection against anemia. These results suggest that iron-deficiency contributes to anemia. Dietary intake of heme iron (or lack thereof) influences variation in hemoglobin levels. In addition to meat consumption, BMI is positively associated with hemoglobin concentration. This implies that general dietary intake also influences hemoglobin. Greater fat reserves may also offer protection against infections that cause anemia. Despite the potential benefits of greater fat reserves, BMI is positively associated with diastolic blood pressure. However, another measure of body composition, waist circumference, is negatively associated with diastolic blood pressure.

Socioeconomic status and wage earning Mid-high socioeconomic status is positively associated with BMI, arm circumference, waist circumference, calf circumference, and sum of five skinfolds. These relationships are absent for women of high SES. In fact, professional employment of the primary household wage earner (in teaching, nursing, ministry) was negatively related to BMI, arm circumference, waist circumference, and sum of skinfolds. High socioeconomic status was positively associated only with calf circumference. Although women with the highest socioeconomic status have greater access to resources than other women, resource availability is not contributing to greater fat reserves as in the case of middle-high SES. High SES may not always be beneficial, especially when poverty is widespread in the same community. Women of high socioeconomic status must deal with jealousy, resentment, and demands for support from others. Alternatively, these women may be able to afford more nutritious foods that are lower in fat and calories. Some women of high socioeconomic status reported dieting or consciously trying to avoid becoming overweight or obese. 162 Low SES is negatively related to hemoglobin. Access to resources (or lack thereof) influences women’s risk for anemia. Poor women tend to have lower hemoglobin than women of higher SES. However, lack of a wage earner in the household (because of disability, old age, or the lack of a male partner) was positively related to BMI. This result suggests that women in these household are successfully drawing upon support from their extended families or other community members to meet their caloric needs. Earning substantial wages (the woman herself, not her spouse) is negatively related to systolic and diastolic blood pressure. These results suggest a link between women’s economic autonomy and health. Women who earn high wages are less economically dependent on their spouse and therefore may experience less stress and insecurity. Earning low wages, by occasionally selling baked goods or washing clothes is not significantly related to blood pressure, perhaps because these wages do not offer the same autonomy and economic security as working in nursing, teaching, or running local stores. Having a spouse who works in agriculture is negatively associated with diastolic blood pressure. This seems counterintuitive given that men who work at sea can earn much higher wages than those who sell agricultural produce and/or work as wage laborers in other peoples’ fields. However, working at sea does not necessarily translate into household economic security. The bulk of men’s wages never make it to the household. Instead, men spend large amounts of money on alcohol, luxury items for themselves, and other women. Men’s irresponsible spending contributes to conflict within the household. Women report men’s behavior and domestic fights (both nonviolent and violent) as stressful events that incite anger, worry, and high blood pressure.

163 Household composition and social support Household composition is related to women’s body composition. Average age of household members is positively associated with arm circumference and waist circumference, suggesting that women in older households have greater fat reserves. However, the percent of household members under age 15 is positively associated with waist circumference, which indicates that women in households with more children also have greater abdominal fat reserves. Average age of household members is also positively associated with systolic blood pressure and diastolic blood pressure. Women often explained that as children age they become sources of stress and anxiety given the costs of educating them and the likelihood that they will cause problems (e.g., boys begin drinking and fighting, girls become pregnant without establishing stable, approved relationships). Also, women in households with older, dependent members may experience greater levels of stress as they try to make decisions and meet household needs. Establishing partnerships with men is also related to body composition. Being married or in a stable union is positively associated with calf circumference. Number of male partners is positively associated with arm circumference and calf circumference. Women who have had relationships with more men may have acquired more support during their lives than women who have had no partners or just one partner. This support, whether it is from the men themselves or from their social support networks may influence women’s body composition. Another possibility is that fatter women (fatness is a sign of health and attractiveness) partner with more men during their lives. Social support also appears to influence blood pressure levels in complex ways. Having a mother and father who are still alive are both positively related to diastolic blood pressure. Yet, living near maternal relatives is negatively associated 164 with diastolic blood pressure. These results suggest positive effects (less stress) for women who can draw on support from maternal relatives, but negative effects for women who must meet parental expectations of support. Parents expect women to provide increased help with workloads, money, and food as they age, while still maintaining a subordinate position relative to their mothers and fathers. Although these roles may burden women, the general availability of maternal relatives (not just parents, but also sisters, brother, aunts, uncles, etc.) who help with food, money, workloads, childcare, and advice may relieve stress. Membership in a community organization is also negatively associated with diastolic blood pressure. Belonging to churches and other groups may increase women’s social support networks, their self- esteem, autonomy, sense of importance and control over their future (Dominguez and Watkins 2003; Scheyvens 2003).

Reproduction In terms of the relationship between reproduction and health, morbidity during pregnancy is linked to more indicators of compromised health than any other variable. Experiencing morbidity during previous pregnancies (proportion of pregnancies where morbidity was reported) is negatively related to BMI, arm circumference, waist circumference, and sum of skinfolds, but positively associated with diastolic blood pressure. These results connect complications during pregnancy (rather than birth or during the postpartum period) to lower fat reserves and higher blood pressure. Women’s experiences during reproduction, rather than just reproduction itself, are related to their general health status. The average length of birth intervals is positively related to mid-calf circumference. Thus, how far women space their children appears to influence at least one measure of body composition. Sterilization is negatively associated with 165 hemoglobin. The manner in which sterilization exerts an influence on hemoglobin is unclear. Sterilization may proxy for another underlying and unidentified factor. For instance, women who become sterilized may do so because of high parity after closely spaced births and/or perceived declines in their own health. Lower hemoglobin levels among these women may signal that their health continues to be compromised even after they attempt to buffer their well-being. Zero parity is positively related to hemoglobin. Women who have not made investments in reproduction appear to be able to maintain higher hemoglobin than women who have experienced live births. However, high parity is not significantly related to indicators of health. Current pregnancy and lactation are negatively related to hemoglobin, suggesting that while women are making the most expensive investments in reproduction, they are unable to maintain hemoglobin levels and are at higher risk of developing anemia. Post-reproductive status is negatively associated with arm circumference. Women beyond their reproductive years may experience decreasing fat and/or muscle in the upper arm region.

9.4 Health outcomes: Is there a relationship between maternal health and reproduction? In the case of maternal health in Miskito communities, gravidity and parity are either inappropriate measures of investment in reproduction or women are not experiencing health consequences (at least in terms of fat reserves, hemoglobin status, and blood pressure) as a result of the number of investments they have made in reproduction. Results indicate that young women and women currently investing in reproduction (either pregnant or lactating) are more likely to experience negative health outcomes than older, non-pregnant women of high parity. Parity, as an indicator of investment in reproduction, may be a crude measure. The actual number of reproductive events may be less important than women’s experiences during and between 166 reproductive events. For instance, women who experienced more morbidity during their pregnancies (regardless of total number of pregnancies) had lower fat reserves and hemoglobin levels. Likewise, shorter average birth intervals were associated with smaller calf circumferences. Table 9.1 (adapted from Tracer 2002) shows a list of studies that did and did not document evidence of LH trade-offs between investment in reproduction and maternal health. All sixteen studies tested whether women’s nutritional status was negatively associated with parity. Weight, or weight controlled for height, skinfolds, and arm circumference were used as indicators of maternal health. Lower fat reserves were associated with higher parities in eight cases. These negative trends in body composition with higher reproductive investment are most likely to occur in populations that experience the highest rates of caloric restriction (e.g., foragers, horticulturalists) (Tracer 2002). In populations with diets adequate in calories, like the Miskito villages in this study, measuring the costs of reproduction is more complex than looking at changes in fat reserves with increasing parity. Instead, investigating changes in body composition, micronutrient status, and health/immune status over the course of individual women’s lives - during adolescence, pregnancies, lactation, birth intervals, and menopause - is necessary to capture changes in well-being that may be related to investments in reproduction.

167 Studies finding no significant trends or positive trends in indices of maternal condition with parity

Source Site Maternal condition index Adair (1984) Taiwan Weight Prentice et al. (1981) The Gambia Weight Hamman (1981) Egypt Ponderal index Khan and Raza (1981) Pakistan Ponderal index Bertan et al. (1976) Turkey Ponderal index Guzman et al. (1976) Philippines Ponderal index Pisharoti et al. (1976) India Ponderal index Miller and Huss-Ashmore (1989) Lesotho BMI, Triceps skinfold

Studies finding significant negative trends in indices of maternal condition with parity Source Site Maternal condition index Ochoa and Gil (1981) Colombia Ponderal index Azar et al. (1976) Lebanon Ponderal index Nahapetian et al. (1976) Iran Ponderal index Little et al. (1992) Kenya Sum of 4 skinfolds Venkatachalam (1962) Papua New Guinea Weight Harrison et al. (1975) Papua New Guinea Sum of 4 skinfolds Garner et al. (1994) Papua New Guinea Weight, subscapular skinfold, arm circumference, BMI Tracer (1991) Papua New Guinea Sum of 3 skinfolds

Table adapted from Tracer 2002

Table 9.1 Results of studies that examined the relationship between parity and maternal condition

Some women may be able to invest successfully in both reproduction and somatic maintenance. Genetic variation in the ability to resist disease or use energy efficiently may explain why some women maintain health despite difficult circumstances (Stearns 1992). These women may also have higher fertility (and therefore, higher fitness) as a result of their better overall health (Hill and Hurtado 1996). Women who are unable to maintain health may also experience lower fecundity and fertility. Although trade-offs are expected, life history theory recognizes that positive correlations between reproductive investments and somatic maintenance may emerge (Partridge and Sibly 1992). An evolutionary framework assumes that over generations natural selection will favor women who could produce many 168 offspring, maintain their own health, and survive. Women who cannot meet the demands of reproduction have fewer offspring and/or do not survive. Either way, they contribute fewer genes to the next generations. Women’s vulnerability to poor health is shaped largely by resources available. Results here suggest that a political economic perspective may enrich our understanding of factors influencing reproductive costs. Life history theory assumes energy is limited in most contexts and that individuals may vary in their access to and efficient use of energy. However, LH theory does not explain why this assumption is not always true or why variation in individuals’ access to resources varies to such extremes within the human species. Variation in access to and use of energy is key to understanding why some individuals experience trade-offs among growth, maintenance, and reproduction and others do not. Genes, biological processes, and ecological conditions influence energy availability and use. Today, variation in access to different types of resources is particularly pronounced given a global economy that benefits some participants and marginalizes others (Goodman and Leatherman 1998). A political economic perspective focuses on larger forces that create and maintain variable access to resources that may contribute to biological differences and health disparities within and among populations. Access to resources influences adaptive strategies that people may use to buffer health. Constraints on women’s abilities to protect their well-being produce vulnerability to poor health (Leatherman 2005). In this case, the limited healthcare budget of a poor country, dangerous and insecure wage labor opportunities, and patriarchy serve as barriers to improvements in women’s health.

9.5 How do women buffer health? Women use multiple strategies to buffer their health from the potential costs of reproduction. During pregnancy, women report doing less physically intense 169 work, rest more often, and try to eat high quality, nutritious food. Most women wean previous children when they discover a new pregnancy. Although they believe that pregnancy influences milk quality and can cause illness in children, they also explain this as a strategy to maintain maternal health. Like women in many other populations (Bohler and Bergstrom 1996; Cantrelle and Leridon 1971; Gray 1992; Hill and Hurtado 1996), Miskito women avoid the burden of concurrent pregnancy and lactation by weaning the previous infant whenever possible. Many women also reported weaning infants when they were losing weight, regardless of their reproductive status. Women and their families use both biomedical and traditional medicine to prevent and treat complications that arise during pregnancy, birth, and the puerperium. They seek help from midwives, private nurses, doctors and traditional herbalists depending on the perceived cause of their health problem. After birth, women ideally rest for one month or more. They concentrate on childcare for the newborn infant while relatives, friends, or paid employees take over their domestic duties of cooking, cleaning, and laundry. During this period they stay at home and avoid sexual intercourse, cold air, cold and/or contaminated water and other potential disease vectors. Women with many young children have the highest workloads in Miskito villages. They rely on family members, particularly maternal relatives, to provide help with their workloads, childcare, and advice. Children, especially girls, are expected to help their mothers with household tasks as soon as they are capable. By their early teen years girls are cooking, cleaning, and providing childcare to their siblings. As women age they continue to shift more of their workloads to their daughters. Older women often report very low or no workloads because their daughters complete domestic duties. 170 Women also use contraception and sterilization to space births and avoid future pregnancies. Women perceive longer birth intervals as beneficial in terms of lower workloads and better maternal and child health. However, they also attempt to avoid childbearing at older ages, because they believe women’s energy levels are lower and health risks are higher. Comparisons with ASFRs in the 1990s suggest that women’s fertility in older age cohorts is declining. With a mean age at last birth of 33.5 years, these low later rates may be better explained by parity-dependent fertility control than age-related declines in fecundity. Public health officials and family planning advocates may view spacing births closer when women are in their 20s as risky for maternal and child health. Studies have documented health consequences of high fertility and closely spaced births for women and their children (Christian 2000, Alam 1995; Bohler and Bergstrom 1995; Madise and Diamond 1995). However, given cultural preferences and socioeconomic needs for large families, women perceive closely-spaced births when they are young as a strategy to protect their long-term health while achieving high fertility. The benefits of having many children may outweigh the benefits of maintaining maternal health in the short-term.Women attempt to attain their desired family size before the risks of childbearing become too high (at older ages). Though this strategy may jeopardize maternal health when women are young (young women are disproportionately represented among anemic women and maternal deaths), women perceive the consequences of this strategy as less severe than the costs reproduction can have later in life. Women’s decisions to stop childbearing are based on many different social, economic, and biological factors. Some women choose sterilization for health reasons, even when they have not achieved their ideal family size. Women who experienced repeated complications during previous pregnancies and birth (e.g., giving birth to seven breach babies) often reported these episodes of morbidity as 171 reasons for sterilization. Women choose to follow doctor’s recommendations to stop bearing children, when they, too, believe that future reproduction would endanger their health. They also use these recommendations to convince their spouses that sterilization is necessary and to garner the resources required to support the costs of travel and surgery. Other women continue to bear children despite complications or warnings from nurses or doctors. In these cases, women either view failure to attain their desired family size as riskier than potential health problems or they lack the resources necessary to prevent conception. Women’s strategies to buffer their health reflect their perceptions of risk. Childbearing is energetically expensive and complications that endanger women’s health may arise. Women constantly monitor their own health and make behavioral adjustments as necessary. When stressors move them away from homeostasis, their well-being depends on shifting work burdens to others, or lowering their investments in reproduction by weaning infants or using contraceptives. Women believe that the demand of childbearing can best be met when they are younger and have more energy. They identify older ages, specifically the late 30s and 40s, as the period of highest risk for complications during pregnancy and birth. How do women’s perceptions of vulnerability compare to biomedical understandings of risk and actual measures of health status in the population?

Morbidity and mortality associated with pregnancy and childbirth generally follow a ‘U’ or ‘J’-shaped curve for age and parity (McCarthy and Maine 1992). Women at both extremes – youngest and oldest, lowest parity and highest parity – have greater risks of poor outcomes. In Miskito communities, young women who have experienced less than two pregnancies, rather than older, high parity women are not only more likely to have lower fat reserves and hemoglobin, but are also disproportionately represented in reports of maternal deaths. Older, high parity 172 women seem less likely to experience a reproductive toll on their health. Perhaps this indicates that older, more experienced women’s attempts to buffer health have been more successful than attempts by young, inexperienced women who have only recently completed growth and development.

9.6 Factors that restrict women’s abilities to buffer their health Women’s access to material and non-material resources influences their abilities to make use of the above strategies to promote their own well-being. The availability of adequate, nutritious food and healthcare depends on whether a woman (or her household) can afford these resources. Poverty prevents women and their families from traveling to hospitals when health problems arise. Likewise, women of low socioeconomic status often lack access to the funds necessary to prevent future conception through sterilization. Regularly including high quality foods like meat and vegetables (e.g., tomatoes, broccoli, green beans, green peppers) in the diet also requires high financial expenditures. Although women desire these food items, prices continue to increase and local market availability is low, especially during the moratorium. Women’s abilities to buffer their health by garnering necessary resources and/ or shifting workloads to other people depend on their socioeconomic status and their social support networks. Most households cannot afford to hire employees to complete domestic duties. Instead, women rely on relatives and friends to help them during times of need. Women who lack access to social support cannot rest for the ideal one month period after birth because no one is available to take over her domestic chores. Living close to maternal relatives is particularly important because mothers and sisters usually help with workloads during pregnancy and after birth. Women who do not live in close proximity to maternal relatives often express their desires to remedy this situation in the future. Having daughters also becomes increasingly valuable as a woman ages 173 because they begin helping with domestic work when they are young and continue to support their mothers even after they establish their own households. Women also meet emotional and material needs by drawing on support from friends, who tend to be members in the same organizations (e.g., churches, communal banks, cooperatives). Women who are not members of a community organization have fewer opportunities to expand their social networks. A woman’s autonomy also influences her ability to use the strategies she believes are necessary to maintain positive health status. Autonomy generally depends on a woman’s position in her household. Age, gender, and economic independence play important roles in determining a woman’s ability to make decisions about household expenditures, healthcare and contraceptive use. Young women, whether in relationships with men or parents, hold subordinate positions. Women who do not earn wages on their own depend on their partners, family members, or friends for cash. Higher ranking men or women in the household often dictate household spending. Age and gender also influence women’s autonomy regarding reproductive decision-making. Male partners must usually be in agreement regarding contraceptive use. Although health centers do not require husband’s permission before they distribute contraceptives, unapproved use of birth control pills or injections may provoke accusations of adultery, violent conflicts, and sometimes abandonment. Likewise, women depend on men’s financial support to meet the costs of sterilization and must therefore convince them that this procedure is in their best interest. Other barriers to contraceptive use or sterilization include family members’ beliefs about morality and the dangers of these drugs or procedures. Spouses or parents who argue that using contraceptives is a sin or will lead to cancer often influence women’s decisions to use family planning services. How these specific factors influence women’s abilities to buffer their health is reflected in the statistical results of this study. Age, socioeconomic status, wage 174 earning, and social support are all significantly related to health. A woman’s social and economic status is an important determinant of maternal health. Women with greater access to resources can lessen the potential costs of reproduction and protect their health. When constraints reduce adaptive strategies, women become more vulnerable to negative health outcomes.

9.7 Study limitations The major limitation of this study is that cross-sectional data cannot be used to make causal statements. Statistical analysis provides information regarding significant relationships among health, reproduction, biodemographic, and socioeconomic factors. However, determining cause and effect is constrained by an imperfect knowledge of which factors preceded others in time. Other limitations are related to the logistics of conducting research in remote, rural villages. Transportation services between households and villages are non-existent during the moratorium and irregular during the rest of the year. Walking from household to household and village to village with research equipment requires considerable amounts of time and energy. The journey between the outer most villages in the research site is about four to five hours on foot. Transportation difficulties prevented the inclusion of more women in the study and in some cases limited the number of times individual women could be interviewed and assessed for health status. Women’s movements to work in fields on the other side of the lagoon or to visit family members in other villages also limited their availability for monthly interviews. Traveling to villages beyond the Ibans lagoon or to a city to replenish supplies is also time consuming and difficult. The lack of infrastructure in the department requires that most traveling is done by canoe, pick-up trucks on the beach, or airplane. Time and resource limitations prevented the completion of a larger maternal mortality survey with an adequate sample size for estimating maternal mortality ratios 175 and lifetime risk of maternal death. I chose to use the sisterhood method (see Graham et al. 1989) to collect detailed accounts of maternal deaths (i.e., verbal autopsies) only in communities along the Ibans lagoon instead of traveling to other villages where cross- checking ages and reports of maternal deaths would not have been feasible given time constraints. As a result, although this study includes detailed information regarding 55 maternal deaths, it lacks estimates of maternal mortality rates for the region. The survey of maternal mortality should be updated and extended to Miskito communities beyond the Ibans lagoon. By increasing the area of the survey, adequate samples for estimating mortality ratios and lifetime risk of maternal death can be attained. Although measuring hemoglobin levels using the Hemocue® method provides information necessary to calculate anemia prevalence among Miskito women, without more data, the specific causes of anemia remain unspecified. Potential causes include iron or other micronutrient deficiency or parasitic infection. Given interethnic mixing with populations of African descent, hemoglobinopathies cannot be excluded as possible causes either. Methods to test for iron deficiency and parasitic infection were not included in the original study because of concerns that more invasive techniques would dissuade women from participating in the research project. In reality, community members generally welcomed the rare opportunity to learn about their hemoglobin status and future studies that identify micronutrient deficiency and parasitic infection will most likely be met with the same interest. A closer look at the etiology of anemia in Miskito communities is necessary. This includes investigating iron deficiency, malaria parasite density, and hookworm fecal egg counts among individuals. Both micronutrient deficiencies and parasitic infections potentially influence the prevalence of anemia in this population. Identifying causal factors would help clarify not only which individuals are at risk of anemia, but why they are at risk. 176 9.8 Significance of results Understanding maternal health in Miskito communities expands theoretical modeling of LH evolution and reproductive trade-offs while culturally focusing public health interventions. Prior to this study, information on maternal health among Miskito women was limited. Previous research had indicated that both fertility and maternal mortality rates were high in this region. Data obtained in 2005 were used to identify women’s multiple health issues facing this population, as well as factors associated with individual variability in health. Here, proximate and ultimate determinants of fertility and maternal mortality were examined within the context of evolutionary theory and LH. Particular attention was paid to women buffering their health within the constraints of a marginal environment to determine adaptive strategies. The biocultural approach used integrated evolutionary theory, ecological models, and political economic perspectives to create a complex picture of the processes shaping variation in women’s reproduction and health. Hopefully, these results will inform public health initiatives addressing maternal health in these communities. Conclusions drawn by this study will be presented to participating research communities, local governmental and non-governmental organizations in the future.

Establishing population parameters of women’s health Human population biology developed to examine environmentally structured variation in biology, physiology, and health across populations. An early interest in genetic adaptation influenced this focus on the population as a major unit of analysis. Populations can be any group of individuals who interact regularly and share a gene pool, ecological conditions, and sociocultural features (Johnston and Little 2000). To observe differential survival and reproductive success requires long and rather 177 unfeasible study designs. Therefore, indicators of health, nutritional status, and growth have been used to study more complex aspects of human adaptive responses to environmental conditions (Huss-Ashmore and Thomas 1997). Research reported here contributes to these goals by examining population measures of health, analyzing factors that jeopardize individual well-being, and examining how one population copes with sociocultural, economic, and ecological stressors. Information on women’s health in this population and risks endangering their well-being have been identified. These Miskito population parameters allow comparisons between this population and others and offer a benchmark for determining changes in maternal health over time. This study is the first survey of body composition, hemoglobin concentration, and blood pressure carried out at the population level among adult women in Miskito communities along the Ibans lagoon. Although women were not randomly sampled, the sample represents women of different ages, parities, and reproductive status. The results give a fair estimate of maternal morbidity, overweight and obesity, anemia, and hypertension. This research also updates past analyses of fertility in these communities (see Dodds 1994; 1998) and is used to examine changes in patterns of childbearing over the thirteen years between studies. Fertility appears to be declining in Miskito villages, albeit at a modest rate. Although large families continue to fulfill social, economic, and psychological needs, the vast majority of women report that parents should have fewer children because they can no longer support eight or more children. Women do not necessarily prefer smaller families, but they report feeling constrained by increasing costs of food, clothes, education, and healthcare. Demographic transition theory predicts that when mortality rates fall, birth rates will eventually follow this downward trend as living conditions improve and modernization forces act on populations (Kirk 1996). If the decrease in total fertility from 8.2 in 1992 to 7.7 in 2005 in fact indicates that a demographic transition is underway in Miskito communities, this offers demographers 178 an opportunity to analyze not only why women in contemporary populations begin to have fewer children, but also how they accomplish new fertility goals. Some demographers have emphasized the role of stopping behavior rather than birth spacing to explain fertility declines in historical populations (Knodel 1983; 1988; Wilson et al. 1988). Although spacing and stopping are not mutually exclusive, stopping behavior (e.g., a younger age at last birth) indicates deliberate, parity- dependent fertility control (Wood 1994). In Miskito communities, although women use breastfeeding, traditional herbs, birth control pills and injections to space births, they voice a preference for sterilization. This method of family planning allows them to stop reproducing when they reach a particular family size. However, decisions to become sterilized may depend on more than just achieved parity (i.e., a specific number of children). Rather, the ratio of boys to girls, age range and mortality of previous children, maternal health experiences, and household resource availability influence women’s desires and abilities to become sterilized. Likewise, terminating reproductive capacity at a particular age may not always translate into smaller families. Women’s age specific fertility rates indicate closely spaced births, especially in their 20s. Although the mean age at last birth for women beyond their reproductive years is 33.5 years, high fertility continues due to rapid childbearing prior to this age.

Documenting and explaining intra-population variation Human biologists are not only interested in variation in health and fertility between populations, but also within them. Aggregating individuals into populations can mask the true range of variation in health status and fitness and conceal important factors that create differences in local biology. This study documents intra-population variation in reproduction, morbidity, body composition, hemoglobin concentration, and blood pressure levels. Statistical analysis was used to test hypotheses regarding 179 the relationships among measures of health and various socioeconomic, demographic, and biological factors for women living in Miskito communities. Age, socioeconomic status, wage earning, autonomy, social support, household composition, diet, and body composition variables were associated with health indices. Investment in reproduction is also associated with health indicators, though not always in expected ways. Results support the primary hypothesis of this study – that investment in reproduction has consequences for maternal health status. The risks of maternal morbidity and mortality remain high for women in these resource-deprived communities. However, instead of finding a cumulative toll on women’s health with repeated reproductive events, costs seem to be highest for young women, women currently pregnant or lactating, and women who have experienced proportionally higher rates of morbidity during previous pregnancies.

Implications for evolutionary theory and human adaptability Trade-offs between reproduction and maintenance are not always easily or clearly demonstrated by simple analyses. Identifying and using adequate indicators of reproductive investment and maternal condition for populations with adequate caloric intake remains difficult. This may be due to an inappropriate focus on the number of reproductive events (e.g., parity, gravidity) instead of women’s experiences during reproductive events. Although the sampling strategy of this study attempted to exclude pregnant and newly lactating women, the significance of recalled experiences during reproductive events (i.e., morbidity during pregnancy) for health status suggests that this research avenue is worth exploring further in the future. The alternative explanation is that in populations where women are able to meet caloric needs, reproduction does not take a cumulative toll on health. Lack of significant relationships between high parity and various indicators of health imply 180 that women who have experienced many live births are no more likely than low parity women to experience health problems. Miskito women may be investing heavily in reproduction relative to other populations; however, they do not produce anywhere near the biological maximum number of offspring possible (see Wood 1994). Intentional and non-intentional fertility control may buffer women from higher reproductive investments that potentially jeopardize maternal health. Other biological, demographic, and socioeconomic variables explain more of the variation in health outcomes among women in Miskito communities than parity or gravidity. For this population, women who are currently investing in pregnancy or lactation and women who have experienced morbidity during previous pregnancies are more susceptible to trade-offs. The presence of trade-offs reflect different levels of physical, emotional, and economic vulnerability. Likewise, the absence of trade-offs points to resilience and human adaptability. Issues of power and inequality influence human-environment interactions and are therefore important to the study of human biology and health (Leatherman 2005).

Integrating evolutionary and biocultural approaches to study maternal health The discipline of anthropology traditionally recognizes the importance of a holistic perspective to understand the human species. Anthropologists define humans not only as biological organisms, but also cultural beings. Culture and biology are linked together in a dynamic feedback relationship. This complex relationship between biology and culture is perhaps no where more evident than in the production of human health (McElroy 1990). This study demonstrates the importance of using a biocultural approach to analyze maternal health in Miskito communities. Biological, ecological, sociocultural, political and economic factors interact to produce specific reproductive and health outcomes. Disease, illness, and death occur because women 181 cannot overcome every stressful assault to their health. Physiological and environmental constraints place limits on human adaptability (Baker 1984). The specific constraints that lead to vulnerability in this case include poverty, gender inequality, and a general lack of material and non-material resources. Ecological forces have played important roles in creating human biological variation, but social inequalities and larger political economic factors also shape a considerable amount of the variation that we see in growth and development, reproduction, and health today (Goodman and Leatherman 1998). The ability to meet biological needs and maintain health depend not only the availability of resources within an ecosystem, but also on hierarchies of power that influence the use and distribution of resources among individuals and groups. By integrating evolutionary, cultural, and political economic perspectives, the biocultural approach holds promise for achieving a complex understanding of how humans respond to multiple and varied stressors. Historically, human population biology’s focus on the physical environment to the exclusion of the social environment (see Huss-Ashmore and Thomas 1997) served as an obstacle to biocultural studies. Rethinking and redefining the environment in a more comprehensive and complex manner is necessary to study the biological, cultural, social, and political economic factors that constrain humans’ adaptive strategies and create variation in health and demographic characteristics within and between populations. The model of the environment employed in this study considers the links between physical, social, and cultural realms. Whereas human population biology concentrates primarily on physiology, genetics, demographic structure, growth and development, biocultural researchers also emphasize how individuals are situated within specific sociopolitical contexts (McElroy 1990). Miskito women often find themselves in a double-bind given widespread economic insecurity and gender ideologies that place them in subordinate positions. 182 Human biologists who use biomedical frameworks to study health tend to ignore or downplay the social origins of disease (Wiley 1993), despite the fact that people in the populations they study clearly define the roles of poverty, inequality, and social conflict in creating poor health outcomes. Examining ultimate causes of impaired health complements models of proximate causes drawn from biomedical paradigms. The types of responses (whether physiological, developmental, cultural, or behavioral) that people use to cope with stressors depend on the cultural context and the material and non-material resources that are available to individuals. Responses maybe costly and differ substantially in terms of effectiveness. People are often forced to make concessions in terms of short and long term health (Wiley 1993). Miskito women’s strategies to deal with meeting the need for many offspring in an environment where reproduction is risky are to space births closely when they are young and more energetic. This tactic may jeopardize their short-term health and their lives, but they lack other options given the importance of large families and perceptions of increasing vulnerability with age. Young women’s potential sacrifices are evident in their higher rates of anemia and higher risks of succumbing to complications associated with pregnancy and childbirth. If they survive to older ages, the sacrifices they made earlier in life may allow them to protect their health in later life. A biocultural approach thus encourages researchers to reconceptualize stress.

Humans typically face multiple, varied, interactive and unpredictable stressors that challenge their ability to respond. This requires human biologists to examine the origins, range, and influence of different stressors (Wiley 1993). For example, social obligations and economic demands to produce children impact health risks because they influence reproductive decision-making among Miskito women and their partners. A more holistic view of stress also focuses on what people perceive as threatening (Huss- Ashmore and Thomas 1997). Psychosocial stress, especially related to the loss of control 183 over resources experienced due to exploitation or “modernization”, has emerged as an important research topic with critical links to chronic and infectious disease. Miskito women often reported economic insecurity and social conflicts related to alcohol and drug use as the cause of health problems such as headaches, high blood pressure, lack of appetite and inability to sleep. Historically situating populations helps biocultural theory correct its past failure to address the relevance of social inequalities and exploitation (principally due to colonialism and imperialism). For hundreds of years, the Miskito people have been exploited by the global capitalist system and have fought many battles to gain control over land and other resources. Despite their resilience, political and economic marginalization continues to deprive households and communities of the resources that promote well-being (e.g., healthcare, clean water, nutritious food) and instead introduces inequality, dangerous jobs, drugs, and alcohol. Integrating contemporary processes with the depth of time provided by evolutionary theory (with its explanatory mechanisms like natural selection) strengthens the biocultural approach to maternal health. A look at recent history and ecology may be able to account for human variation in exposure to biological dysfunction, but it does not explain why people within shared environments (physical and/or social) experience stress differently. Important questions about susceptibility cannot be answered without investigating individuals’ biology, social networks, perceptions, and behaviors. Ecology, evolution, culture, and political economic forces create variation in health.

Implications for public health Data collection was successful largely because the overarching goal of this research –to study maternal health in a vulnerable population – resonated with participants and other community members. Despite the awkwardness of undergoing 184 anthropometric measurements, the embarrassment of answering personal questions and the difficulty recounting painful stories of loss, women were willing to participate in the study because so many are eager, if not desperate, to make their needs known. The costs of maternal morbidity and mortality are borne not only by individual women in these villages, but also by their families and communities. By obtaining and analyzing women’s reports of their health problems and day-to-day struggles, this study has generated information with practical applications. Results may inform public health initiatives to prevent and treat maternal health problems by targeting particularly vulnerable members of the population. Efforts should focus on extending resources to young women, pregnant and lactating women, and women that lack economic security, social support, and nutritious food. The high prevalence of anemia among adult women indicates that improvements in coverage and quality of health care are necessary. The supplementation of target populations – especially young, pregnant women – with iron and folic acid is necessary given the risks they face. More importantly, health centers need the equipment and supplies to identify and treat infections (especially malaria and hookworm) that can lead to or exacerbate anemia. Given the links between anemia and negative birth outcomes, addressing high rates of anemia now could prevent future maternal morbidity and mortality. Improving hemoglobin levels prior to delivery may prevent some complications from becoming severe and life-threatening. This represents an important intervention given that most births occur at home and women lack access to emergency obstetric care. Although infectious and parasitic diseases are stressors in this population, results suggest that chronic, non-infectious diseases associated with modernization will increasingly account for health burdens in the future. Given the high rates of obesity, women’s risks of diabetes, hypertension, and cardiovascular disease are also high. Many 185 women report symptoms of these diseases and/or assume they suffer from these health problems despite the lack of diagnosis by trained medical professionals. Treatments for chronic disease at the local level are extremely limited. Generally only women of high socioeconomic status can afford to travel to a better equipped health center or hospital for diagnosis and treatment. Despite some health practitioners’ claims, women in these communities are neither ignorant, nor do they reject Western biomedicine. They do prefer to be treated compassionately, particularly when emergencies arise, by the doctors and nurses who live in their communities. Lower user rates of health centers typically signal women’s dissatisfaction with the limited hours, lack of supplies, and inadequate diagnostic services available. For instance, the health center in the village of Cocobila could rarely keep prenatal vitamins in supply for pregnant women. Community members report a preference for more access to biomedical services rather than less. Women state a need for more doctors, especially female, Miskito doctors who are present year-round. Local midwives also expressed desires to attend training sessions. Many problems could be addressed with minimal increases in financial commitments from the government. Given the limited resources of the Honduran government, health initiatives by non-state and para-statal actors are particularly important. However, in the Mosquitia most groups have focused on biodiversity conservation and much less on human development and health. There are local organizations, like MOPAWI, that are attempting to link conservation, development, and health; yet they require assistance and support from larger actors with more resources and emphasis on improving health and well-being (e.g., WHO, PAHO).

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207 APPENDIX A IRB APPROVAL

208 209 APPENDIX B HOUSEHOLD AND LIFE HISTORY SURVEY

210 ID#______Date/Time______

Household Composition and socioeconomic information

Household Composition

Genealogical Sex Age Date of birth Relationship Education level

Income/ Market Activities: 1. What are you family’s biggest expenses? 2. How do you earn money to pay for your family’s expenses? a. Do you work for anyone in the community? i. Who? ii. What do you do? b. Do you sell anything? i. What? ii. To whom? 3. Does anyone else in your household help you earn money to pay for expenses? a. Who? b. What do they do? 4. Do you share money with extended household members? a. Who, why, and how often? 5. What items do you purchase regularly? 6. Where do you normally purchase items? 7. Do you feel like you have enough resources to take care of your daily needs? (all of the time, most of the time, some of the time, rarely, never) 8. Do you feel like you have enough resources to care for your children? (all of the time, most of the time, some of the time, rarely, never) i. Do you feel like you have enough money to pay for medical bills, school fees, and food?

9. Who are the people that help you the most with: a. Food 211 b. Money c. Labor/Work d. Childcare e. Advice

Productive assets: 1. Does your family own land? a. You? b. Your husband? 2. Do you feel like your family has access to enough land to meet its needs? 3. What type of crops does your family usually grow? a. For consumption? b. For sale? c. How many people do you usually cook for each day? 4. Do you do any activities such as fishing, hunting or gathering to supplement agricultural activities? a. What activities? b. How often? 5. Do you own any trees? a. What kind? b. How many? 6. Do you have animals? a. Number of chickens b. Number of pigs c. Number of Cows d. Others 7. Does your family own a canoe? a. How many? b. Do any of the canoes have a motor? How many? 6. Do you own a sewing machine?

Residence/Mobility: 1. How many physical residences do the members of this household use? a. Where are they located? b. When do you use them?

Material Goods: 1. Do you own any of the following? b. Generator c. Refrigerator d. Stove e. Radio

212 f. Bike g. Others?

Additional notes about the household:

ID#______Date/Time______

Life History

9. Place of residence 10. What month and year were you born? 11. Where were you born? 12. Where were you raised? 13. How old are you? 14. What is your first language? 15. Do you speak any other languages? Which? 16. What is your ethnicity? 17. Have you ever attended school? a. How many years? b. Where? 18. Is your mother still alive? a. Where does she live? b. What language does she speak/ what ethnicity is she? c. How old is she? d. How many children has she had? e. How many children did your grandmother have? 19. Is your father still alive? a. Where does he live? b. What language does he speak/ what ethnicity is she? c. How old is he? d. How many children does he have? 20. How many brothers do you have? 21. How many sisters do you have? 22. Who are your older siblings?

213 Sex Age Still alive? Misc.

23. Who are your younger siblings?

Sex Age Still alive? Misc.

24. Have you ever been married/lived with a man? a. How old were you when you were married/lived with a man for the first time? b. Why did you decide to marry him/live with him? c. Where did you live? d. In whose house? e. How many men have you been married to/lived with? f. Are you currently married/living with a man? If so, for how long? How old is he? 25. How many times have you changed residence/moved after you married for the first time? a. Where did you live before? 26. How many children have you given birth to? a. How many are still living? b. How old were you when you first gave birth? 27. Are you pregnant? a. Are you using birth control or sterilized? Why or why not? 28. Are you breastfeeding? a. How long have you been breastfeeding? b. When are you going to wean your youngest child? 29. Are you experiencing any health problems at this time?

214 30. If you or your children are sick what do you do? a. Who makes decisions about going to the health clinic/hospital or healer? b. Is good health care available if you need it? Where? 31. Are you involved in any community organizations? a. Which? b. What do you do?

215 APPENDIX C REPRODUCTIVE HISTORY QUESTIONAIRE

216 ID #______Date/Time______

Reproductive history questionnaire

1. Have you ever been pregnant? 2. How many times have you been pregnant? 3. Have you ever given birth? 4. How many children have you given birth to? 5. How many sons live with you? 6. How many daughters live with you? 7. Do you have any sons or daughters to whom you have given birth but do not live with you? a. Where do they live and why? b. How long have they lived there? c. Have they lived anywhere else? 8. Have you ever had a miscarriage? a. How many? b. How many months pregnant were you? 9. Have you ever given birth to a boy or girl who was born alive but later died? a. How old was the child? 10. Have you ever given birth to a child that cried or showed other signs of life but only survived a few hours or days? 11. In all, how many girls died? 12. In all, how many boys died? 13. You have had a total of ______births in your life? 14. Are you currently pregnant? If so, when do you expect to give birth? 15. How old were you when you first menstruated? 16. How old were you when you became pregnant for the first time? 17. How old were you when you had your first child? 18. Children (in order of birth):

217 Still living? If no, Name Sex Date of Place of birth when did he/she Same fathers? birth die? Cause?

19. Have you ever experienced any health problems during pregnancy, during childbirth, or soon after childbirth? When? Which child? What were they?

Pregnancy Labor/birth After birth

Bleeding (severity?) Prolonged labor Bleeding (severity?) Seizure/convulsions High fever Seizure Swelling Seizure/convulsions High fever High fever Bleeding (severity?) Infection: Yellowish eyes/skin Tearing (fever, lower High blood pressure Fistula abdominal pain, Paleness Prolapsed uterus lower back pain, Dizziness Others discharge) Fatigue Fistula Headache Others Discharge Nausea Others 20. Did anyone attend the births of your children? Who (relationship)? 21. What is your current reproductive status? (Check all that apply) ( ) Menstruating ( ) Not menstruating (amennorhea) for unknown reason ( ) Breastfeeding ( )Pregnant ( ) Using birth control ______( ) Sterilized 22. When was your last menstrual period? 23. How often do you usually have a menstrual period? 24. Have you ever breastfed a child? How many? a. How long do you usually breastfeed a child before weaning him/ her? (Months/years) b. How do you decide when to wean a child? 25. Are you currently breastfeeding?

218 a. How long have you been breastfeeding? b. How many feedings are in the morning_____ afternoon______evening______night____ 26. Have you ever experienced problems with breastfeeding? 27. Do you want to have more children? How many? 28. Does your husband want to have more children? How many? 29. How much space is it good to have between two pregnancies? 30. What is a good number of children to have? 31. When you think about having more children, what is the thing that worries you the most? 32. Do you know of good ways to have children when you want to, or to not have them? 33. Have you tried any of these methods? Which? What does your husband think? 34. What kind of health problems do your children have most often?

219 APPENDIX D MONTHLY INTERVIEW QUESTIONAIRE

220 ID#______Time/Date______

Monthly Maternal Health Questionnaire

Dietary Intake 1. Over the last 48 hours, what did you eat and drink?

Two days ago Yesterday Today

Morning

Afternoon

Evening

Night

2. In a typical week, how often do you eat/drink the following?

Additional notes Food How often (Type, quantity, preparation) Rice Corn (boiled/tortillas) Fish Beef Chicken Other meat Beans Eggs Plantains Green vegetables Tomatoes Onions Oranges Other fruit Fruit juice Water Tea Coffee Alcohol

3. Do you feel like you get enough food?

221 a. All of the time b. Most of the time c. Rarely d. Never

4. Do you feel like your children get enough food? a. All of the time b. Most of the time c. Rarely d. Never

5. Is there any type of food you would like to have more often?

Time allocation 1. Over the last 48 hours what have you done (including work and non-work activities)

Two days ago Yesterday Today

Morning

Afternoon

Evening

Night

2. How much time do you usually spend doing the following activities each day? Activity Time Additional notes Sleeping Visiting with others/socializing Buying supplies Preparing food Eating/drinking Cleaning Washing clothes Gathering firewood/water Taking care of children Doing agricultural work Animal care Working for someone else Manufacturing, repair Bathing/grooming Religious activities Relaxing Other

222 3. Are your workloads usually: a. Heavy b. Moderate c. Light

4.This past month were your workloads: a. Heavier than usual b. The same as usual c. Lighter than usual

5. If your workloads were different than usual, why? How?

Health/Morbidity

1. Have you had any health problems/illnesses in the past month? Illness episodes: When Illness Symptoms Duration Intensity Treatment Misc. (interfered with activities)

2. Did you get sick more often/less often this month? a. What kind of illnesses have increased/decreased?

3. What sort of treatments have you used this month? a. Hospital medicine? b. Traditional medicine? c. Why did you choose this treatment?

4. Have you experienced any stressful events this month? a. Type? b. Time of day? c. Scale (Mild, Moderate, Severe)? d. How long did it last? (minutes, weeks, days)? e. How did you respond to the event?

5. Have you had problems eating this month? a. Why? b. How often?

6. Did you have trouble sleeping this month? a. Why? b. How often?

223 7. Have you had any family/marital conflict this month? a. What type? Who was involved (relationship)? b. How long did they last? c. How did you respond to this event?

Additional Information:

Socioeconomic status 1. Update household information. Are there any new animals, productive assets, or material goods? 2. Has your household income gone down or up this month or has it stayed the same? Why? 3. Do you feel like you have enough resources to take care of your daily needs? If no, please explain. 4. Do you feel like you have enough resources to care for your children? If no, please explain. 5. Have you had enough money to pay for medical bills, school fees, and food? If no, please explain.

Social Support 1. How many visitors have you had this month? a. who b. how long c. reason for visit d. do you give them money, food, or household items when they left a. did they bring you money, food, or household items when they came

2. Have you visited anyone this month? a. who (relation) b. how long c. reason d. did you give them money, food, or household items e. did they give you money, food, or household items

3. Have you asked anyone for food this month? a. who (relation) b. when c. Did they give you the amount you asked for?

4. Have you asked anyone for money this month? a. who

224 b. when c. Did they give you the amount you asked for?

5. Have you asked anyone for help with childcare this month? a. who (relation) b. when c. Did they help with childcare for as long as you needed? How long?

6. Have you asked anyone for help with your work (agricultural, domestic, other) this month? a. who (relation) b. when c. Did they provide the help you asked for? d. How long did they work?

7. Have you asked anyone for advice on everyday concerns this month? a. who (relation) b. when c. Did they give you advice? d. How long did they talk with you?

8. Has anyone asked you for food this month? How often?

9. Has anyone asked you for money this month? How often?

10. Has anyone asked you to help with childcare this month? How often?

11. Has anyone asked you to help with work this month? How often?

12. Has anyone asked for your advice on everyday concerns this month? How often?

225 APPENDIX E MATERNAL MORTALITY SURVEY

226 ID#______Date/Time______

Maternal Mortality

1. How many sisters (born to your mother) have you ever had who lived to be at least 15 years old? 2. How many of these sisters are alive now? 3. How many of these sisters have died? 4. How many of them died while they were pregnant, or during childbirth, or during the six weeks after the end of pregnancy?

(If any sisters died while they were pregnant, or during childbirth, or during the six weeks after the end of pregnancy continue with the following questions)

5. When did she die (month of pregnancy, during childbirth, weeks after birth)? 6. What was the cause of death? 7. Where did she die? 8. Was anyone taking care of her/attending her birth? Who (relationship)? 9. Did she receive prenatal care? 10. Did the child survive? 11. Did she have any other children? a. Who took care of the children after her death (relationship)? Why?

227