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 By 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. v 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