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American Indian women have poor perinatal outcomes and are at risk for early childbearing. The purpose of this qualitative study was to understand the experience and meaning of early childbearing among American Indian women.
Employing interpretive phenomenology and a semi-structured interview guide, 30 adult American Indian women residing in a Northwestern American Indian Reservation were interviewed about their experience and meaning of early childbearing.
Three overarching themes were tied to their eventual positive evaluation of the experience: 1) mourning a lost childhood, 2) seeking fulfillment, and 3) embodying responsibility.
Women indicated that despite their tumultuous childhoods, early childbearing presented an opportunity to effect positive change in their lives. Midwives and nurses are positioned to help women change their lives; thereby, improving health outcomes.
Despite a general downward trend in the US birth rate among older adolescents (aged 15 to 19) from 1991 to 2005, teen birth rates rose by 12% for American Indians/Alaskan Natives, 6% for African Americans, and remained the same for Hispanic teens from 2005 to 2007.1 Compared to White teen birth rates (25.6 births per 1,000 live births), rates are increased by two to three-fold among the American Indian (55.5 per 1,000), African American (59 per 1,000), and Hispanic (70.1 per 1,000) populations.2 General risk factors associated with early childbearing, or teen pregnancy, such as early onset of sexual activity, lacking access or poor use of contraception,3 living in poverty, having parents with low education levels, growing up in a single-parent household and performing poorly in school,4 are well recognized risk factors in the American Indian/Alaskan Native population.5, 6
Precise adolescent childbearing outcomes for American Indian women are difficult to identify because they represent a small population and there are contradictions among federal, state and tribal criteria for this identification. When compared to Hispanic and White childbearing women, American Indian women have higher risks of low birth weight, preterm birth, post neonatal death and infant mortality.7 They are more likely to abuse substances,8 experience interpersonal violence while pregnant,9 use little to no prenatal care,10, 11 and report elevated depressive symptoms,12 thus often placing their own child at adverse risk.
Numerous studies have been conducted to identify the experience and meaning of early childbearing for young mothers. For some women, it is an attempt to stabilize their chaotic lives, thereby binding themselves to a partner13 in search for unconditional love.14 Additionally, young motherhood can be a transformative experience acting as a catalyst for positive life changes13, 15–20 including, mending broken relationships,21 affirming their mothering role,15, 22, 23 developing goals, enacting responsible activities and heralding optimism.16, 17, 19, 23, 24 Depending upon their social and cultural disposition, some characterize early childbearing as a normative rite of passage.23
Within the American Indian culture, pregnancy and childbirth are viewed as normal life course events irrespective of maternal age,25, 26 and are frequently celebrated with private and public ceremonies, singing, and gifts. Among American Indian adolescents, early childbearing has been found to validate one's feminine role,26 but also may be a time for loneliness and suicidal ideation.27 Early childbearing is more likely to be seen as a condemnable offense by the dominant White culture.28–30 Although recognized as a problem, some studies have shown American Indian community members, teen mothers, parents and partners are more accepting of early childbearing.26, 27, 31, 32 Researchers point out it is not the particular timing per se, but the valued birth of a new community member that yields support.25, 31
Little is known about American Indian women's perspectives of the experiences and meaning attributed to early childbearing. It is helpful for scientists, midwives, nurses, and tribal communities to understand their perspectives in order to develop effective health care strategies and interventions for this population. The purpose of this study was to explore reservation dwelling adult American Indian women's recollected perceptions and meaning of their early childbearing experiences at the time of becoming pregnant.
Collaborative approaches are needed when engaging American Indian communities as a result of past exploitation and marginalization of this population.33, 34 A philosophical orientation to community based participatory research, a research method that seeks to equalize power between the researched and researcher,35 was used in this study. The participating tribe provided collaboration and oversight over all aspects of the study project. Anonymity for the tribe is central to the collaborative agreement, and thus the exact community is not named.
This retrospective interpretive phenomenological study received joint approval from the University of California San Francisco Committee on Human Research and the collaborating Tribal Nation. American Indian cultural practices and philosophical views value the personal story, or lived experience. Interpretive phenomenology, as described by Heidegger36 and applied early to nursing research by Benner,37 regards individuals as situated in their life world where they both create and are created by their situation. This method emphasizes the circumscribed possibilities available for individuals based upon the context of their “situatedness” in time (including history), space (physical location), taken-for-granted cultural meanings, and personal concerns. Living in the American Indian world on a reservation often involves poverty, low education attainment,5 and substance use.38 This method was culturally and philosophically suited for revealing American Indian women's experiences of young motherhood because it accounts for the context of their lives including their histories, traditions, physical location residing on a reservation, transitions and everyday comportment, and its engagement of women in a culturally relevant practice of oral storytelling.
Potential participants were recruited by word of mouth, public announcements in local newspapers, and public flyers that were posted in public spaces throughout a Northwestern US reservation. Except in one case, all women contacted the first author and primary investigator, an American Indian nurse, by a local telephone number. One woman was contacted directly by the primary investigator to be screened after verbal consent through a referral from a community member had been obtained. Inclusion criteria were: 1) self identified as a member of the collaborating Tribal Nation; 2) aged 18 and older; 3) experienced childbearing at age 18 or younger; 4) currently lived on the reservation; and 5) willing to share their experiences of being a young mother. Written consent was obtained after each woman was read a copy of the study procedure and consent form.
Data collection began in July 2007 and ended in April 2008. Following a short demographic survey completed by mail or in person, all women were interviewed by the first author using a semi-structured interview guide in a place (eg, homes, parks, cafés, and workplace), time, and method (eg, in person or by telephone) that was convenient for each woman. Six women (20%) preferred to be interviewed over the phone, while the remaining 24 women (80%) were interviewed in person. As garnered through the pilot study conducted with urban dwelling American Indian early childbearing women, the interview guide was augmented to include questions about women's childhoods prior to their pregnancy and began with the open-ended question, “Tell me what was going on when you became pregnant.” Probes were used to elicit examples, such as “Please share a memory of what you did when you suspected you were pregnant.”
Given the pilot study, it was anticipated that up to three interviews would be needed to provide enough time for women to share their story and for the researcher to gain women's trust, due to the sensitive topic and marginalized population. The same interview guide was employed in all three interviews. Women who were contacted a second and third time were asked to elaborate on specific parts of their shared stories for clarification. All women completed the first interview, which averaged 120 minutes. Eight women (27%) completed the second interview that was held between 1 and 3 months following the first interview and 3 women (10%) completed a third interview. Attrition was high by the second and third interview, mostly related to change in contact information and disconnected phone service. Women were compensated $20 cash after each interview. All interviews were digitally voice recorded, transcribed verbatim, and checked for accuracy by the primary investigator. Participant observation and field notes were also documented and transcribed.
The aim of interpretive phenomenology is to uncover commonalities and differences across the phenomenon of study.37 Analysis of interpretive phenomenology is a dynamic, recursive and repetitive process wherein the investigator employs their previous knowledge to the content at hand.39 This serves as a starting point from which the investigator enters the hermeneutic circle, a process of understanding the entire text through understanding each individual part as the parts relate to the whole.36 In the hermeneutic circle, previous and new understandings fluctuate in accordance with the analyzed narratives. All interviews, field notes, observations, and interpretive memos were entered into ATLAS.ti (Scientific Software Development, Germany), a qualitative program that aids data organization for coding. Analysis was conducted according to the triadic process described by Benner37 that included paradigm cases, thematic analysis, and exemplars. Each interview was repeatedly read for an overall understanding and a summary was written, creating a paradigm case. Similarities and comparisons were made across paradigm cases (summaries) by means of thematic analysis, a method of identifying meaningful patterns and concerns. Finally, exemplars were selected to demonstrate a particular salient situation or meaning.
Rigor in qualitative research is to accurately portray the participants' experience. All transcripts were transcribed verbatim, as a means to enhance rigor.40 As data analysis begins with interviews according interpretive phenomenology, the primary author summarized and paraphrased understanding to participants throughout the interview process, in an effort to engage in member checking,41 a method to ensure credibility of the study. Conformability and dependability were accomplished by an audit trail.41 Periodic collaborative analytic review of the findings with professional nursing colleagues and reflexive journaling used by the primary investigator helped to identify assumptions and ideas.42 The presented women's names are pseudonyms and all identifiable information was changed to protect confidentiality.
Demographic information is listed in Table 1. On average, women became pregnant at 16.1 and ranged from 14 to 18 years old. Many turned a year older at delivery. The average age at the time of the first interview was 35.5 and ranged from 20 to 65 years old. Despite circumstances, women were academically motivated. Most (n = 28; 94%) either achieved their high school diploma or obtained their General Equivalency Diploma (GED).
Women's trajectories into early childbearing are reported elsewhere.43 Oriented to the world as young indigenous, impoverished women they described chaotic and diminished childhoods that often set them upon a risky path. Wedged between childhood and young adulthood, competing concerns created existential turning points for these women. With the experience to look back and evaluate their past, women shared the significance of early childbearing as: 1) mourning a lost childhood, 2) seeking fulfillment, and 3) embodying responsibility (see Table 2).
Mourning a lost childhood expressed the tumultuous and isolating aspects of early childbearing. Becoming a young mother was often described as a surrealistic experience: “It was like a whirlwind.” Barriers in the community, in her family, and within herself at times characterized this as a troublesome time. Some women felt ashamed of their pregnancy and took measures to conceal their condition. Ignoring the symptoms of her pregnancy at age 15, Cleone, who played the entire varsity basketball season pregnant recounted memories of her denial.
I was able to jump, and at the time I didn't know you weren't supposed to do it. It did hurt to jump, and it killed to rebound, but I hid it. I remember being in the bathtub and seeing my stomach move, and I remember just pushing, “Stop! I can't be pregnant!” Because I had my mind convinced that I had my period, that there was no way I could be pregnant. But even seeing my baby move, I still said, “I'm not pregnant. I'm not pregnant.” And I would purposely lay on my stomach so that nobody would think about it. God it was hard to breathe… [and later] It was like a stigma. If you were Indian, female and then got pregnant, you would drop out and never finish school. I fit that mold and I was ashamed of fitting that mold.
Cleone's identity as a young pregnant Indian woman was at odds with her expectations for her future and identity, creating immense shame. This shame led to self harm of rigorous physical activity and methods of concealment, potentially endangering her pregnancy.
Loss was also discussed in terms of childhood. Cienna became pregnant at age 15 and likened the dramatic changes precipitated by her pregnancy to a whirlwind as she transformed from a high school cheerleader to a married mother on welfare by age 17 Similarly, Jade who at age 15 became pregnant, mourned her lost dream of attending college when taking on young motherhood.
Many women wistfully reflected on a childhood that could never be recovered and a disintegrating anticipated future. Looking back they recognized in some ways their pregnancy filled a void.
Feeling a void in their life, some women revealed that they sought fulfillment through love and affection. In Jade's experience, young motherhood narrowed life's opportunities, but also filled an emotional void.
My mom has never told me that she has loved me. Never. We didn't have affection, like motherly affection, because she grew up without a mom. I just firmly believe that's how you learn to love, to nurture, and about compassion, from your mother. And she didn't have one. She knew how to provide for us, but she didn't know how to give love. And, that's something I always wanted was love, and just to feel that someone needed me, and that's what I was lacking. So when I had my son, he needed me and he was someone to fill that void.
Jade's pregnancy happened when she felt emotionally isolated. Given her circumstances, she was determined to cultivate an interdependent relationship with her son that was absent from her childhood.
Some women sought a partner to fulfill their emotional needs. Describing herself as a “little hellion” who partied (used substances), two years later Mariel found herself pregnant. Coming from a broken family and a slew of foster care experiences, Mariel confided that she purposely stayed with her older abusive boyfriend who “said the things I wanted to hear.”
Women sought an emotional sanctuary where their love and affection would be reciprocated; although not always met, many women viewed childbearing as a positive force that changed their lives.
Embodying responsibility was characterized by three subthemes (Table 2). These included a) reorganizing life, which described the epiphanic experiences that motivated the women to move toward responsibility; b) confirming adulthood, which characterized the actions and experiences that reinforced the women's responsible behavior; and c) curbing risky activities, which explained how the women steadily progressed toward responsible behavior and away from destructive lifestyles. Most women (n = 22) indicated that early childbearing created avenues for them to assume responsibility for themselves and their infant. Some expressed how it may have been instrumental in curtailing substance abuse problems or risky activities like partying.
Reorganizing Life: “It was a turning point for me”
Yadira started drinking at age 13 in response to absent, drug-dependent parents. Despite her boyfriend's denial of paternity, she wanted to settle down. Becoming pregnant at age 15 refocused her life.
As soon as I found I was pregnant though, it was a whole different turning point for me. I didn't touch a drop of alcohol after that. I continued my education. At that time, I was going to [school], and it was a little bit hard. But I think I made it all the way up until the seventh month of going to school. And I dropped out until after she was born, and went back to school… That didn't last very long. I ended up not even lasting a year, and dropped out in my junior year. I didn't receive or go for my GED until I was 19 and pregnant with my second child.
For Yadira, pregnancy was the impetus that gave her the strength to reorganize her life. She stopped drinking and doggedly pursued her GED, actions that illustrate how young motherhood positively refocused her life.
Confirming Adulthood: “…working hard for my son”
Confirming adulthood was seen in women's actions and how they took up their childbearing status. After moving out from her parents' home when she became pregnant at age 14, Stephanie remarked that she needed work to support herself.
I had to go to work and I was working and going to school at the same time. And a lot of my friends were not working and were having fun…they were not working to support themselves. They worked to do whatever they wanted with their money. I was working hard for my son. That was what I thought was important and that had not even crossed their minds. So, that made me grow up. I had to support somebody. I was making $5.50 an hour and trying to support another person. That was hard for me.
Stephanie recognized that working for her child set her apart from her friends who worked essentially for pocket money. For her, working was a means to survive, to bring food home, and to support her family. In contrast to her friends who spent their money indiscriminately, Stephanie carefully watched her expenses day by day, an embodiment of adult responsibilities and behaviors.
Curbing Risky Activities:“That is not the way I want to be.”
Some of the women described motherhood as destiny, a fateful event that prevented them from stumbling down the “rocky road” to continued substance abuse and other risky behaviors. Early childbearing became a source of inner strength for these women, reminding them of the difficult situations they had survived and protecting them from present and future hazardous behaviors.
Valerie felt that early childbearing protected her from further substance abuse because she learned how to be responsible when she became pregnant at age 14.
I think that it has showed me more responsibility. That you have to work for what you want, and I did. I would walk to the local gas station and buy diapers because that was what I had to do. I think it gave me more responsibility and made me realize that you have to deal with it … I would not do it any other way now. I mean what would my life be like if I did not have my children? I would still be one of those girls running around all skinny and screwed up looking. Drunk… and that is not the way I want to be.
Having children positively affected Valerie's life. She realized that her children not only enriched her life but also motivated her to model positive behaviors and activities rather than self-destructive behaviors.
The women in this study ascribed a range of meanings to their early childbearing, which reflected present concerns and experiences.
Loss of a childhood and expected future hastened devastation. Women, like Cleone, felt shame in their pregnancy by losing normalcy and gaining stigma. For Cleone, early childbearing was condemnable as a derogative stereotype and she sought to mask her condition by engaging in strenuous activity and at times inflicting self harm born through her denial. Work by Atuyambe et al44 among adolescent Ugandan mothers found a prevalent sense of shame and powerlessness related to lack of support from family or the father of their baby, rather than loss of social station; however, it was not noted if shame resulted in self-harm. A recent review of the National Violent Death Reporting System by Palladino et al45 found that older American Indian women were more likely to be victims of pregnancy associated suicide. Despite older women being at greater risk for suicide, young women like Cleone are at risk for self harm and endangering their pregnancy.
Despite differences in culture and location, findings are similar to Hannah's vulnerable Australian White homeless adolescent mothers who viewed early childbearing as an attempt to bring love into their lives.13, 14 Partnered or not, women in this study resolutely and repeatedly sought someone who would accept and reciprocate their love and affection, It is unclear in this study if young motherhood healed broken relationships as has been demonstrated by Williams and Vines.21
Early childbearing can be meaningful and positively impact young women. Among homeless street youth, motherhood was often met with ambivalence as youth remembered their troubled childhoods, but at times it acted as a catalyst for self improvement.19 Echoing motivation for positive transformations, findings by Crawford et al16 found despite high incidences of substance use and post traumatic stress disorder among homeless teen mothers, early childbearing encouraged women to change their lives by ending substance use and seeking help. A recent Australian study, conducted with indigenous teen mothers, found that despite disruptive childhoods filled with physical and sexual abuse, neglect and poor relationships with their mothers, motherhood was viewed as a transformative event that gave meaning to their chaotic lives as they undertook steps to take responsibility and hoped for a better future.17 Kaye22 found that while some adolescent Ugandan mothers continued a trajectory of tumultuous challenges extending from their childhood into early motherhood, most mothers enacted positive coping strategies, especially viewing their pregnancy in terms of a new role with status. A study of adolescent mothers in Belgium identified that for some women, early childbearing served as an escape route from unbearable living situations (e.g. household filled with abuse).24 Additionally, positive aspects were identified such as the pregnancy helping to bolster their sense of self worth, maturity and responsibility, similar to Arenson's15 landmark study. In addition to seeking mature roles and practices, some young women desire to parent their child “better” than their parents had parented them.18
While women in this study did not view early childbearing as a route out of their household and tumultuous childhoods, nor did they immediately enact corrective parenting measures, early childbearing was viewed as an opportunity for positive changes. Women found motivation for curbing risky behaviors (e.g. substance use) and reorganizing their life to become more responsible (e.g. pursuing their education). Moreover, early childbearing confirmed their mature identity through tasks to become a responsible mother (e.g. working to provide for their child). Due to the nature of this study, interviewing adult women on their reflected early childbearing experience, it is uncertain whether or not these participants held positive future expectations given their early childbearing status as has been documented by others.16, 17, 19, 23, 24
Women in this study expressed multiple meanings of early childbearing and were not limited to one theme. For example, while Jade shared her view of young motherhood eclipsing her scholastic goals, it did provide a means to emotional security. Contrary to Horn's26 study with urban adolescent American Indian mothers, this study did not find motherhood to validate their feminine role. Furthermore, descriptions of traditional ceremonies were not discovered and may reflect the variance within this culture, the degree of colonization/assimilation, and the intimate meanings attributed to their experience.
Despite the immediate negative effect on these women's education, all but 2 women (6.6%) either graduated high school or received a GED. Rarely is academic attainment reported for this population. Situated within her community, both her educational attainment and ensuing responsibility may have been facilitated by her American Indian culture, perhaps reflecting a normative perspective on early childbearing. Further study is warranted to decipher what role academic motivation has in improving early childbearing outcomes and impact on experiences.
Findings from this study do not represent all American Indian women's experiences. American Indians differ in geographical locations, language and cultural practices. However, a shared colonized history, continued marginalization and impoverished circumstances, may create similar situations wherein these findings may apply to other American Indian women. This study is limited to those who self identified, and those who participated may be situated differently in life (e.g. not using substances, open to sharing, employing positive parenting practices) than those who did not. Furthermore, differences in degrees of sharing may be present among those who selected to meet in person to be interviewed versus those who opted for phone calls. Attrition rate at the second (27%) and third (10%) interview was high, likely reflecting women's unstable financial situations, and may have affected the depth of understanding acquired by the primary author as member checking was limited. Finally, these findings are remembered accounts reflecting events anywhere from 2 to 50 years ago, which are historically biased. Differences in recollections may play a factor in shaping one's story.
An overarching sense of optimism and strength for positive changes permeated these young women's discussions, which contrasts with mainstream beliefs and expectations.20, 46 Given their education and interpersonal skills, midwives and nurses are uniquely positioned to illicit the significance of an early pregnancy for a young woman. Directly asking, “What are your thoughts on being pregnant” may provide space for the woman to share hopes and fears. Results from this study illustrate stigma impacts women's experience of pregnancy. Key to one's assessment is determining the young woman's risk for self harm with overt and covert methods. Simultaneously, an assessment of her risk for harming her pregnancy is important. Asking young women, “Have you sometimes felt you needed to hide your pregnancy?” may lead to disclosure of intentional injury. Keeping in mind that American Indian women are at risk for poor perinatal outcomes, regardless of age, midwives should assess early childbearing women's living situation, support and coping methods. American Indian women are at an elevated risk for substance use, and helping them identify and end their risky behaviors may help prevent and delay childbearing. While early childbearing may be viewed by the young woman as filling an emotional void, midwives and nurses should recognize the potential for positive life changes and help establish healthy parenting practices. For the community, early childbearing may play a protective role curbing riskier behaviors that result in death and further study is needed to identify whether or not cultural ties are stronger with young mothers. Moreover, additional research is needed to identify important measures that promote supportive childbearing and parenting outcomes for this vulnerable population.
Early childbearing presented the women in this study with an opportunity to carve out new roles and embrace distinctive actions. These women demonstrated unanticipated discipline: they stopped their substance abuse, exchanged their nomadic ways for settled lives, and pursued employment and education. Young motherhood demonstrated how capably these women could handle adult responsibilities; they turned their lives around with newfound resolve to complete their education, to pursue employment, and to nurture and love their children.
Many of the women in this study believed becoming a mother was their salvation. Many ominously concluded that their lives would have taken a drastically different turn had they not become pregnant. Continued substance abuse and criminal behavior defined their limited life's vision. They needed a compelling reason to drop their risky lifestyles and to build a stable life of their own. Mothering was that opportunity.
While completing this research, Janelle Palacios was supported by NIH NINR NRSA 1F31 NR009627-01 (PI: Palacios), NIH NIGMS 1R25 GM56847, NIH NINR 5T32 NR007077-14 and funding from the University of California, San Francisco Graduate Division and School of Nursing, including the Cota Robles and Lanctot Fellowships, and Century Club Award. The authors extend gratitude to those women who participated in this study. Thank you for sharing your stories
Janelle Palacios, CNM, PhD is a practicing nurse midwife and is postdoctoral fellow at UC Los Angeles School of Nursing.
Catherine “Kit” Chesla, RN, DNSc, FAAN is the Thelma Shobe Endowed Chair in Ethics and Spirituality in the Department of Family Health Care Nursing at UC San Francisco.
Holly Kennedy, CNM, PhD, FACNM, FAAN is the Helen Varney Professor of Midwifery at Yale University of School of Nursing.
C. June Strickland, PhD, RN is an Associate Professor in the Psychosocial & Community Health Department at the University of Washington School of Nursing
Conflict of Interest The authors have no conflicts of interest to disclose.