Adolescent pregnancies in the Amazon basin of Ecuador : a rights and gender approach to girls' sexual and reproductive health

Adolescent pregnancy has been associated with adverse health and social outcomes, but it has also been favorably viewed as a pathway to adulthood. In Ecuador, where 20% of girls aged between 15-19 years get pregnant, the adolescent fertility rate has increased and inequalities between adolescent girls from different educational, socio-economic levels and geographical regions are prominent: 43% of illiterate adolescents become pregnant compared to 11% with secondary education. The highest adolescent fertility rates are found in the Amazon Basin.   The overall aim of this study was to explore adolescent pregnancy in the Amazon Basin of Ecuador (Orellana province) from a rights and gender approach. Specific aims and methodologies included: to explore women‟s reproductive health situation, focusing on government‟s obligations, utilization of services, inequities and implementation challenges, assessed through a community-based cross-sectional survey and a policy analysis (Paper I); to examine risk factors associated with adolescent pregnancy, through a case-control study (Paper II); to explore experiences and emotions around pregnancy and motherhood among adolescent girls, using content analysis (Paper III); and to analyze providers‟ and policy makers‟ discourses on adolescent pregnancies (Paper IV).   Reproductive health status findings for women in Orellana indicated a reality more dismal than that depicted in official national health data and policies. Inequities existed within the province, with rural indigenous women having reduced access to reproductive health services. In Orellana, 37.4% of girls aged 15-19 had experienced pregnancy, almost double the national average. Risk factors associated with adolescent pregnancy at the behavioral level included early sexual debut and non-use of contraception, and at the structural level poverty, having suffered from sexual abuse, and family disruption. Gender inequity played a key role through the machismo-marianismo system. Girls were raised to be fearful and ignorant regarding sexuality and reproduction, to be submissive and obedient, to be fatalistic, and to accept the established order of the male and adult dominance. Sexuality was conceptualized as negative, while motherhood was idealized. Those gender structures constrained girls‟ agency, making them less able to make choices regarding their sexual and reproductive lives. Providers‟ discourses and practices were also strongly influenced by gender structures. Adolescent sexuality was not sanctioned, girls‟ access to contraceptives still faced opposition, adolescent autonomy was regarded as dangerous, and pregnancy and reproductive health issues were conceptualized as girls‟ responsibility. However, mechanisms of resistance and challenge were also found both among adolescent girls and providers.   Programs addressing adolescent pregnancies in the area need to look at the general situation of women‟s reproductive health and address the gaps regarding access and accountability. Adolescent pregnancy prevention programs should acknowledge the key role of structural factors and put emphasis on gender issues. Gender inequity affects many of the factors that influence adolescent pregnancies; sexual abuse, girls‟ limited access to use contraceptives, and girls‟ curtailed capability to decide regarding marriage or sexual intercourse, are strongly linked with young women‟s subordination. By challenging negative attitudes towards adolescents‟ sexuality, the encounter between providers and adolescents could become an opportunity for strengthening girls‟ reproductive and sexual agency.