INCIDENCE OF EARLY PREGNANCY AND SELF REPORTED GYNECOLOGICAL SYMPTOMS AMONG TRIBAL COMMUNITY IN INDIA

 
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INCIDENCE OF EARLY PREGNANCY AND SELF
REPORTED GYNECOLOGICAL SYMPTOMS
AMONG TRIBAL COMMUNITY IN INDIA

A. K. RAVISHANKAR

Introduction                                   8.21 percent of the country’s total
                                               population.2
   In general, most tribal populations
inhabit under-developed areas of the
                                                  Tribal women in India experience sexual
country, which are remote, having low
                                               debut as married adolescents. Moreover,
density of population and lacking in
                                               large surveys have found that almost half
adequate access to basic amenities,
                                               of all tribal women aged 20–24 are married
education, employment opportunities and
                                               by age 16 in India.3 High level of poverty,
affordable health care services.
                                               inadequate health resources, ignorance and
   Indian tribals are known for their          high-risk beliefs and practices among the
unique ways of living, distinct culture,       tribal communities has contributed to the
traditions, beliefs and practices which        vulnerability of this population. There is
provide them a distinct identity on the        a general consensus that the health status
national scene. They are spread across the     of the tribal population is very poor and
country mainly concentrated in the states      worst among the tribes because of their
of Madhya Pradesh, Orissa, Chhatisgarh,        isolation, remoteness and being largely
Maharashtra, Jharkhand and Gujarat.            unaffected by the developmental processes
However, they have their presence              going on in the country.4 Ignorance and
in all States and UTs except Punjab,           high-risk beliefs and practices, high
Pondicherry and Chandigarh.1 According         poverty level, inadequate and in accessible
to 2001 census, tribal population in the       health resources, in the tribal communities
country, was 84.32 million, representing       has contributed to the early marriage/

A.K. Ravishankar, Senior Lecturer, Department of Population Studies, Annamalai University,
Annamalai University, Annamalainagar – 608 002

34                                                        The Journal of Family Welfare
pregnancy of this population. Therefore,        higher education (1.3%). Their husband’s
there is a felt need to study the influencing   educational attainment was much higher.
factors and risks to young tribal women’s       More than half of the tribal families (58.0%)
reproductive health.                            were living in joint families.

Methodology                                        The occupational analysis discloses that
                                                half of the young tribal women were
This study was undertaken to:
                                                not working (49.2%) and 40 percent are
n   explore the pattern of early pregnancies    engaged in agricultural activities. A
    in the young tribal community and its       negligible proportion of the tribal women
    determinants                                were working in the technical and
                                                professional category (0.7%). Almost all
n   study incidence of self-reported
                                                the husbands were workers, 44 percent
    gynecological symptoms among
    the young tribal mothers and its            were engaged in agricultural activities, 39
    association with early pregnancies          percent in manual work and 4 percent in
                                                clerical jobs. One-third of tribal families
n   study the influence of socio-economic       fall in the poorest wealth index category
    and demographic characteristics on          (33.5%) and a little above one-fifth of
    early pregnancy and self-reported           them were in the poor category (22.9%).
    gynecological symptoms among the            Both the richer and richest categories
    young tribal community in India             constitute 24 percent.

Data                                               About two-third of young women
                                                tribes (64.8%) got married before they
   The data were collected from National
Family Health Survey-III5 - nationally          reached the legal age at marriage (18
represented large-scale sample survey           years), 85 percent of these teenagers get
conducted in India during 2005–065. This        into marital life before they attain the
study was focused only on young married         legal age at marriage. The mean age at
tribal women in India. A total of 2,527         marriage of young women was 16.48
currently married tribal women aged 15-         years. Therefore, it is very clear that child
24, were selected from various States and       and early marriages were quite common
Union Territories of India to examine the       in the tribal communities.
association between early pregnancies and
self-reported gynecological symptoms.               Three-fourth of the young tribal women
                                                (74.4%) gave births to their first child before
                                                attaining 20 years of age. More particularly
Findings                                        two-third of the late-adolescent tribal
   Of the 2527 tribal women interviewed,        mothers (15-19 year old) gave birth for the
more than one-fourth of the sample              first time before they reached the age of 18
population fall in the late-adolescents 15-     which has adverse health consequences,
19 and the remaining 73 percent of the          both for the mother and their children.
tribal women were young (20 to 24 age           The mean age at first birth for young tribal
group). More than half of them were Hindu       women was 17.95 years.
(58.1%) and a considerable proportion were
Christian (29.5%). A significant proportion        Knowledge of tribes about ovulatory
of the tribal women were living in rural        cycle was very poor since, forty-two percent
area (80.6%) and more than two-fifth of the     of the teenagers and 37 percent of those
young tribal women were illiterate (43.1%)      between 20-24 years of age did not know
and negligible proportion completed             about the ovulatory cycle.

Vol. 58, No.1, June - 2012                                                                35
TABLE 1                    Characteristic             Number     Percent
Background characteristics of young tribal women
                                                   Marital duration
                   in India
                                                     0-4                       1542       61.0
Characteristic              Number     Percent
                                                     5-9                       914        36.2
Age of the women
                                                     10-14                        69      2.7
  15-19                      669        26.5
  20-24                      1858       73.5         15-19                        2       0.1

Place of Residence                                 Age at 1st birth
  Urban                      490        19.4         12-14                     116        6.2
  Rural                      2037       80.6         15-17                     703        37.4
Religion                                             18-19                     579        30.8
  Hindu                      1466       58.1         20-22                     444        23.6
  Muslim                      59         2.3         23-24                        37      2.0
  Christian                  746        29.5         Mean age at 1st birth    17.95
  Other                      254        10.1
                                                   Total children ever born
Education
                                                     0                         648        25.6
  No education               1089       43.1
                                                     1                         894        35.4
  Primary                    486        19.2
  Secondary                  919        36.4         2                         600        23.7

  Higher secondary            33         1.3         3                         282        11.2

Occupation                                           4+                        103        4.0

  Not working                1241       49.2         Mean CEB                  1.33
  Professional /                                   Knowledge of ovulatory cycle
  Technical Manager           28         0.7
                                                     During her period         121        4.8
  Sales & service             87         3.5
                                                     After period ended        467        18.5
  Agricultural labourer      990        39.2
  Other                      178         7.1         Middle of the cycle       278        11.0
                                                     Before period begins         29      1.1
Household structure
  Nuclear                    890        35.2         At any time               656        26.0

  Joint                      1465       58.0         Other                        4       0.2
  Not dejure resident        172         6.8         Don't know                969        38.4

Wealth index                                          The mean number of children ever
  Poorest                    847        33.5       born (CEB) was 1.33 and mean number
  Poorer                     578        22.9       of living children including the current
  Middle                     493        19.5       pregnancy was only 1.41. The number of
  Richer                     413        16.3       children indicated for a family was 2.66
  Richest                    196         7.8       and seventy percent of the young tribal
                                                   women preferred to have another child in
Age at marriage
                                                   future. It indicates that their fertility level
  Less than 14               576        22.8
                                                   will further increase in future. About
  15-17                      1062       42.0
                                                   sixty percent of the tribal women had less
  18-19                      556        22.0
                                                   than five years of marital duration and
  20-24                      333        13.2
                                                   another thirty-six percent had spent 5-9
  Mean age at marriage       16.48                 years of marital life.

36                                                              The Journal of Family Welfare
Incidence of early pregnancies                                               TABLE 3
   A significant proportion of tribal                 Background characteristics and Incidence of early
girls in India are still expected to marry                              pregnancy
and begin childbearing in their early or             		                         Age at first birth
middle teenage years. However, many lack             Characteristic     Before 18            Above 18
information and support and are incapable            		                12-14     15-17 Under 18 18-19
to obtain the health services that the mother
                                                     Age
and their children need.
                                                      15-19             9.7      63.7      73.4      26.6
                     TABLE 2                          20-24             5.4      31.8      37.2      62.8
            Incidence of early pregnancy
                                                     Residence
		                         Number          Percent
                                                      Urban             5.1      29.3      34.4      65.6
Age at 1st birth
                                                      Rural             6.4      39.4      45.8      54.2
  12-14                     116             6.2
                                                     Household structure
  15-17                     703             37.4
                                                      Nuclear           8.6      41.8      50.4      49.6
Early pregnancy             819             43.6
                                                      Non-nuclear       4.7      35.1      39.8      60.2
  18-19                     579             30.8
                                                     Education
  20-22                     444             23.6
                                                      No education      9.2      47.2      56.4      43.6
  23-24                      37             2.0
                                                      Primary           6.6      41.8      48.4      51.6
Pregnancy after 18 years    1060            56.4
                                                      Secondary         2.4      24.2      26.6      73.4
   Of the 1879 total tribal young women               Higher             –         –         –       100.0
who reported their age at first birth, 116
                                                     Occupation
women (6.2%) had given their first birth
between 12 to 14 age and 703 women                    Not working       4.2      33.1      37.3      62.7
(37.4%) had given their first children at             Agricultural
the age of 15-17. In total about forty-               labourer          7.6      44.0      51.6      48.4
four percent of the tribal women had                  Service          22.2      27.8      50.0      50.0
given their first birth under the age of 18.          Sale             10.0      38.0      48.0      52.0
Further, three-fourth of the young tribes             Clerical           –       44.4      44.4      55.6
had given their first birth when they were            Skilled &
teenagers. It is evident from the analysis            unskilled        10.0      32.5      42.5      57.5
that the incidence of early and teenage               Professional /
pregnancy was quite common in the tribal              Technical          –       30.0      30.0      70.0
community.
                                                     Wealth Index
   The teenage tribal mothers who had                 Poorest           9.9      45.6      55.5      44.5
given their first birth before 18 years of            Poorer            5.3      42.2      47.5      52.5
age constituted 73 percent as against 37.2
                                                      Middle            4.9      33.6      38.5      61.5
percent in young tribal mothers between
                                                      Richer            2.9      28.0      30.9      69.1
20-24 years of age. It is obvious that early
pregnancy was common among late –                     Richest           3.4      19.6      23.0      77.0
adolescents. Getting pregnant before legal               More than half of the illiterate tribal
age at marriage within wedlock was higher            young women (56.4%) had given their
among the rural-based tribes (45.8%) than            first births in their early part of marital
the urban-based tribes (34.4%). The nuclear          life (under 18 year) and this percentage
family structure had comparatively higher            decreases to 48.4 percent among young
early pregnancies than the joint family              girls who had completed primary school
structure (50.4%, 39.8% respectively).

Vol. 58, No.1, June - 2012                                                                            37
education and to 26.6 percent among                      status has little influence on early births.
women who completed secondary school                     Giving birth before the legal age at
education. It can be concluded from the                  marriage was higher among women who
analysis that mother’s age at first birth                were in the poorest wealth index category
decreases with increasing educational                    (55.5%) than the middle and richest
attainment. At the same time, working                    categories (38.5% and 23.0%, respectively).
                                                    TABLE 4
      Odds ratios from logistic regression examining the effect of selected background variables on the
                                         Incidence of early pregnancy
                                                                                      95.0 C.I.for EXP(B)
Variable B S.E. Sig. Exp(B)
						                                                                               Lower         Upper

Age
  15-19 (Ref)				                                                       1.000
  20-24                        1.467         .142             .000      4.336        3.282         5.730

Residence
  Urban (Ref)				                                                       1.000
  Rural                        .140          .156             .370      1.150         .847         1.562

Religion
  Hindu (Ref)			                                              .002      1.000
  Muslim                       .066          .345             .849      1.068         .543         2.101
  Christian                    .486          .129             .000      1.626        1.263         2.093
  Others                       .107          .171             .533      1.113         .795         1.557

Education
  No Education (Ref)			                                       .000      1.000
  Primary                      .158          .143             .270      1.171         .884         1.552
  Secondary                    .983          .139             .000      2.672        2.035         3.508
  Higher                       6.217        5.069             .220    501.120         .024      10334615.97

Occupation
  Not working (Ref)			                                        .018      1.000
  Agriculture                  -.253         .119             .033      .776          .124          .977
  Sale & Service               -.557         .275             .043      .573          .334          .983
  Professional                -1.054         .526             .045      .349          .615          .980
  Manual Labour                .063          .216             .770      1.065         .698         1.625

Wealth Index
  Poorest (Ref)			                                            .795      1.000
  Poorer                       .045          .142             .752      1.046         .791         1.382
  Middle                       .133          .156             .394      1.142         .841         1.550
  Richer                       .183          .192             .342      1.200         .823         1.750
  Richest                      .300          .269             .265      1.349         .796         2.286
  Constant                    -1.571         .218             .000      .208
Log likelihood 2247.179 Cox & Snell R Square.158 Nagelkerke R Square .212

38                                                                    The Journal of Family Welfare
Logistic regression technique has been         The most frequently stated symptom
employed to assess the effect of the each      was excessive fatigue (45%). The next
background variable on the probability         highest reported symptom was swelling
of early child birth, controlling for other    of leg, body or face (29%). Another 12
variables. For this analysis, the dependent    percent of them reported convulsions.
variable considered is ‘Early Pregnancy’,      Vaginal bleeding was reported by negligible
which has been coded as 0 (birth given         proportion (4%) of young tribal women.
under the age 18 years).                                              TABLE 5
   Table 4 shows the effect of socio-           Gynecological symptoms reported by young tribal
economic factors on early pregnancy.                               women
For example, the effect of age - 15-19 age     Gynecological Symptoms                 Percent
group relative to 20-24 age group, holding     Excessive fatigue                        45.1
other predictor variables constant, the        Swelling of leg, body or face            29.3
odds ratio (the probability of not having
                                               Convulsions                              11.8
early pregnancy) is 4.336 times. The
                                               Difficulty with night vision             11.0
effect of place of residence, religion and
wealth index factors on early pregnancy        Difficulty with daylight vision           9.7
does not show any significance. At the         Vaginal bleeding                          3.9
same time education attainment of the
                                               Number of Symptoms reported
respondents and their occupational status
show significance at 5% level. The logistic      None                                   41.4
regression analysis indicates that early         One symptom                            26.2
pregnancy is not consistently improving          2 symptoms                             18.6
with the improving socio-economic                3 symptoms                              7.4
condition of women.                              4 symptoms                              4.1
                                                 5 symptoms                              1.6
Incidence of Self-reported Gynecological
symptoms                                         All 6 symptoms                          0.1
                                                 Any one symptom                        58.6
   Age is an important demographic
variable that determines biological and           More than half of the tribal women
mental maturity. Therefore teenage/young       experienced any one of gynecological
mothers are usually expected to experience     symptom (58.6%). Around 60 percent
the reproductive health disadvantages          (59.4%) among young girls between 15-19
or serious reproductive problems that          years of age and 58.4 percent among young
sometimes lead to mortality. Therefore, this   women between 20-24 years of age had
study attempts to observe the association      reported any one gynecological symptom
between self-reported gynecological            (not shown in table). Almost an equal
symptoms and age-specific pregnancy.           proportion in late-adolescent (24.5%) and
   The young tribal women were asked           young tribal women (26.5%) had reported
if at any time during the pregnancy            only one symptom during the most recent
they experienced any of the following          birth in the five years preceding the survey.
gynecological symptoms/problems for            Another eighteen percent of both the age
the most recent births in the five years       experienced any two problems (Table 5).
preceding the survey (2005-06): Convulsions    Background characteristics and
(not from fever), Swelling of leg, body or     gynecological symptoms
face, excessive fatigue, vaginal bleeding,
difficulty with daylight vision, and             The percentage distributions of Indian
difficulty with night vision.                  young tribes by any one of self-reported

Vol. 58, No.1, June - 2012                                                                 39
gynecological symptoms with their                                           Any one gynecological
                                                  Characteristic
background characteristics are presented          		                          symptom (Percent)
in Table 6. Almost an equal proportion in         Education
late-adolescent (59.4%) and young tribal            No education                    56.0
women (58.4%) had reported any one                  Primary                         61.3
pregnancy-related health problem during             Secondary                       60.6
the most recent birth in the five years             Higher                          47.1
preceding the survey. A small difference          Occupation
was noted between rural (59.1%) and urban           Not working                     56.6
population (56.5%).                                 Agri. Employ                    59.9
   The analysis of educational attainment           Sales & Service                 69.8
of young tribal women and any one self              Skilled & Unskilled             57.8
                                                    Prof., Tech.,                   73.7
reported gynecological symptom shows a
difference between illiterate women (56.0%)       Wealth Index
and higher educated women (47.1%). No              Poorest                          62.3
difference was found among primary                 Poorer                           54.6
and secondary level educated women                 Middle                           53.8
(60%). While analyzing the respondents’            Richer                           58.3
                                                   Richest                          67.1
occupation with any one gynecological
symptom, a similar pattern was noticed.           Age at first marriage
The wealth index analysis discloses that            Less than 14                    53.5
67 percent of the richest young tribal              15-17                           60.1
women reported any one self reported                18-19                           59.7
gynecological symptom, while it was                 20-24                           62.0
reported by 62.3 percent poorest, 55 percent      Age at 1st birth
by poorer and 54 percent by middle wealth           12-14                           56.4
quintile tribal women.                              15-17                           56.6
                                                    18-19                           59.4
   The proportion of any one self reported          20-22                           61.2
gynecological symptom was 54 percent for            23-24                           56.8
women who got married before the age of
                                                     Logistic regression was used to assess
14. This increased with increase in age at
                                                  the effect of each background variable on
marriage.
                                                  the probability of decreasing the incidence
                    TABLE 6
                                                  of self-reported gynecological symptom,
  Tribal women reporting any one gynecological    controlling for other variables. For this
      symptom by background characteristics
                                                  analysis, the dependent variable considered
                          Any one gynecological   is ‘affected with any one gynecological
Characteristic
		                          symptom (Percent)
                                                  symptom’, which has been coded as 0 and
Age of women                                      `not affected’ coded as 1.
  15-19                           59.4
                                                     It is noted from the logistic regression
  20-24                           58.4
                                                  analysis that the chance of getting any
Residence                                         one self-reported gynecological symptom
  Rural                           59.1            does not consistently improve with
  Urban                           56.5
                                                  the improving socio-economic and
Religion                                          demographic conditions of women. The
  Hindu                           57.5            result indicates that the background
  Muslim                          56.1            characteristics of tribal women does not
  Christian                       57.8
                                                  affect the reported incidence of any one
  Other                           66.5
                                                  gynecological symptom (Table 7).

40                                                               The Journal of Family Welfare
TABLE 7
   Odds ratios examining the effect of selected background variables on the reported incidence of any one
                                           gynecological symptom
                                                                                      95.0 C.I.for EXP(B)
Background variable B S.E. Sig. Exp(B)
						                                                                              Lower         Upper

Age
  15-19 (Ref)				                                                      1.000
  20-24                        .052          .127             .682     1.053         .821         1.351

Residence
  Urban (Ref)				                                                      1.000
  Rural                        -.229         .144             .112      .796         .600         1.054

Religion
  Hindu (Ref)			                                              .113     1.000
  Muslim                       -.118         .328             .720      .889         .467         1.692
  Christian                    -.011         .121             .929      .989         .781         1.253
  Others                       -.401         .170             .018      .670         .480          .934

Education
  No Education (Ref)			                                       .009     1.000
  Primary                      -.361         .143             .012      .697         .527          .923
  Secondary                    -.321         .133             .016      .725         .559          .941
  Higher                       .636          .545             .243     1.889         .649         5.498

Occupation
  Not Working (Ref)			                                        .104     1.000
  Prof                         -.842         .541             .120      .431         .149         1.244
  Sale & Service               -.616         .287             .032      .540         .308          .948
  Agriculture                  -.143         .114             .209      .866         .693         1.084
  Manual labour                -.088         .206             .668      .915         .611         1.371

Wealth
  Poorest (Ref)			                                            .000     1.000
  Poorer                       .418          .138             .003     1.519        1.158         1.993
  Middle                       .487          .153             .001     1.628        1.207         2.195
  Richer                       .242          .182             .185     1.273         .891         1.820
  Richest                      -.253         .255             .321      .776         .471         1.281
  Constant                     -.110         .196             .574      .896
Step 1-2 Log likelihood 2412.033; Cox & Snell R Square.023 Nagelkerke R Square.031

Early Pregnancies and Self-reported                      above 18 (45%) (Table 8).
Gynecological symptoms
                                                            Convulsion (not from fever) self reported
   The proportion of women who reported                  gynecological symptom was reported more
the difficulty with night blindness at the               by women who had given their first birth
time pregnancy was comparatively high                    under the age of 18 years (51%) than the
among women who given their first birth                  women who had given their first birth after
under the age of 18 (55%) than at the age of             the age of 18 years (49.1%).

Vol. 58, No.1, June - 2012                                                                             41
TABLE 8                         young women and reproductive health
Age at first birth by gynecological symptoms among   consequences. The background characteristics
              young Indian tribal women              of women has little effect on the incidence
Pregnancy-related      Early       Late              of gynecological symptoms, including
health problem      Pregnancy   Pregnancy   Total    educational status. It can be concluded that
                     Under       Above               the ignorance and high-risk beliefs and
                     18 age      18 age              practices, and inadequate health resources,
                                                     among the tribal communities has contributed
Convulsions (not from fever)
                                                     to the vulnerability of this population.
  Yes                  50.9       49.1      100.0
Swelling of Leg, face/body                               Hence, appropriate/alternate strategies
  Yes                  38.0       62.0      100.0    should be taken to reduce the early
Excessive Fatigue
                                                     pregnancies in the tribal population
  Yes                 42.4        57.6      100.0
                                                     and to strengthen the existing maternal
                                                     care service packages. It will definitely
Vaginal Bleeding                                     reduce the incidence rate of gynecological
  Yes                 41.4        58.6      100.0    s y m p t o m s a n d t h u s i m p r o ve t h e
Difficulty with                                      reproductive health of women. Policy
Day Light vision                                     makers, planners and care providers need
  Yes                 46.0        54.0      100.0    to think not only the resources of the
Difficulty with                                      health care system, but also keep in their
Night Blindness                                      mind about the tribe’s unique customs,
  Yes                 54.8        45.2      100.0    values, beliefs and traditions pursuing in
Any one problem       41.1        58.9      100.0    the health practices and also their isolation,
                                                     remoteness. So a “differential approach”
   The remaining self-reported                       is to be launched for tribal areas, with
gynecological symptoms had been                      differential norms for establishing facilities
experienced more by the women who had                to gear up the existing programmes to suit
given their first birth after attaining the          their specific requirements.
age of 18. Swelling of leg, body /face was
reported by 62.0 percent women above 18              References
years of age and 38 percent of those who             1.   Government of India. 2009. Ministry of Tribal
had given birth before they attained 18                   Affairs: Annual Report 2008-09. New Delhi.
years of age. Similarly more than half of            2.   Ravishankar, A.K. 2008. Prevalence of early
the women who had given their first birth                 pregnancy and its impact on maternal problems
above the age of 18 years reported that they              of Indian young Tribal women. Presented at XXX
had difficulty with day light vision (54.0%)              Annual Conference of Indian Association for the
and vaginal bleeding (58.6%).                             Study of Population, ISEC, Bangalore, Oct 17-19.
                                                          2008.
Conclusion                                           3.   Ravishankar A.K. S., Ramachandran and Subbiah,
                                                          A. 2008. Trends and Issues in Tribal Studies. In:
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marriages and early births are common in                  Communities: Facts from NFSH-II. Soubhagya
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established an inverse association between                Publications, New Delhi, Pp 1-26.
background characteristics of women and              4.   Indian Council of Medical Research. 1998.
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   A significant proportion of young tribal          5.   International Institute for Population Sciences
women had experienced any one of the self-                (IIPS) and Macro International. 2007. National
reported gynecological symptom and the data               Family Health Survey (NFHS-3), 2005-06: India:
have established a base link pregnancy among              Volume I. Mumbai: IIPS.                      n

42                                                                The Journal of Family Welfare
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