Maternal Healthcare Seeking among Tribal Adolescent Girls in Jharkhand

This article presents evidence from a cross-sectional survey on the extent of maternal healthcare seeking among married adolescent tribal girls in Jharkhand and the factors associated with this proclivity. The study findings clearly show that maternal healthcare seeking is limited. A substantial proportion of girls did not receive any antenatal services; nearly all delivered at home and only a small proportion received a post-partum check-up. The findings, based on a primary survey in Lohardagga district in the state, are intended to inform the development of policies and programmes that address the maternal and child health needs of this group in the country.

REPRODUCTIVE HEALTHDECEMBER 1, 2007 Economic & Political Weekly56Maternal Healthcare Seeking among Tribal Adolescent Girls in Jharkhand Sandhya Rani, Saswata Ghosh, Mona SharanThis article presents evidence from a cross-sectional survey on the extent of maternal healthcare seeking among married adolescent tribal girls in Jharkhand and the factors associated with this proclivity. The study findings clearly show that maternal healthcare seeking is limited. A substantial proportion of girls did not receive any antenatal services; nearly all delivered at home and only a small proportion received a post-partum check-up. The findings, based on a primary survey in Lohardagga district in the state, are intended to inform the development of policies and programmes that address the maternaland child health needs of this group in the country. Findings from a number of studies conducted in India indi-cate that adolescent girls tend to be at a greater risk to adverse maternal and child health outcomes than adult women. Evidences from community-and facility-based studies show, for example, that adolescent girls are significantly more likely to experience maternal death than are older women. Estimates derived from a community-based study in rural AndhraPradesh show that in the 1980s, the maternal mortality ratioamong adolescent girls was almost twice that of women aged 25-39 (1,484 versus 706-736 respectively) [Bhatia 1988]. Hospital-based studies reiterate these differences; a national study of 43,550 women in 10 facilities reports, conducted by the Indian Council of Medical Research (ICMR), shows that the maternal mortalityratio among adolescent girls was 645/1,00,000 live births, compared to 342/1,00,000 among adult women aged 20-34 years [Krishna 1995]. Maternal mortality is only the tip of the iceberg. Adolescent girls also experience other adverse outcomes like perinatal and neonatal mortality, which are significantly higher among ado-lescent mothers than among women in 20s and 30s [Kulkarni 2003]. Similarly, several facility-based studies report higher levels of pregnancy-related complications like eclampsia, preg-nancy-induced hypertension, intra-uterine growth retardation and premature delivery [Mishra and Dawn 1986; Pachauri and Jamshedji 1983; Pal, Gupta and Randhawa 1997; Sharma and Sharma 1992; Swain et al 1993] among adolescent girls than among older women.Though pregnancy in adolescence is associated with a high-er likelihood of pregnancy-related complications, there is little evidence that maternal healthcare seeking is more pronounced among married adolescent girls than among married adult women. For example, two-thirds in each group received antena-tal care, and 42-43 per cent delivered with a trained attendant [Santhya and Jejeebhoy 2003]. Current evidence on thefactors that influence maternal healthcare seeking comes largely from studies conducted among women in the broad reproductive age group. Married adolescent girls, even though included in the group, have not been the focus of these studies. Hence, little is known about the factors underlying maternal healthcare seeking specifically among married adolescent girls. Evidence is sparser in the case of disadvantaged groups such as tribal adolescent girls. This paper presents evidence from a cross-sectional survey on the extent of and the factors associated with maternal healthcare seeking among married adolescent tribal girls. The findings of We are grateful to Leela Visaria for valuable comments. Sandhya Rani (pmsrani@tiss.edu) is lecturer, Tata Institute of Social Sciences, Mumbai; Saswata Ghosh (ghosh.saswata@gmail.com) is lecturer, Institute of Development Studies, Kolkata, and Mona Sharan (mona.sharan@gmail.com)is a health consultant with the World Bank.
REPRODUCTIVE HEALTHEconomic & Political Weekly DECEMBER 1, 200757Table 1: Characteristics of Respondents Per Cent (N=250)Age (years) <=17 8.8 18 30.0 19 61.2Education Never attended school 81.2Mean age at marriage (years) 15.1Socio-economic status* Low 34.0 Middle 48.8 High 17.2Type of family Nuclear 5.2 Non-nuclear 94.8Religion Sarna 93.6 Hindu 2.4 Christian 2.4 Others 1.6Tribe Oraon 76.7 Khervar 7.2 Lohara 4.4 Mahili 3.6 Asur 3.2 Munda 2.8 Others 2.4* Based on access to amenities and ownership of household assets.the study are intended to inform the development of policies and programmes that address the maternal and child health needs of this group in the country. Study SettingThe study was conducted in Lohardaga district, Jharkhand. The state of Jharkhand, with a population of 26.9 million, accounts for about 3 per cent of the total population of the country [Regis-trar General, India 2001]. Though Jharkhand is one of the most mineral-rich regions in the country, it ranks below the national average on most social and health indicators. Only 54 per cent of the total population of the state is literate compared to 65 per cent nationally [RGI 2001]. A large proportion of villages in the state do not have access to roads, safe drinking water and electricity [Tewari 2002]. Women in the state marry and have children early; data from the district-level household survey con-ducted in 2002-04 indicates that the median age at marriage for women in Jharkhand is 18.3 years, lower than the national aver-age of 19.5 years. Forty-four per cent of girls and 36 per cent of boys in Jharkhand are married below the legal age at marriage, compared to 28 per cent of girls and 21 per cent of boys nationally [International Institute for Population Sciences 2006]. Similarly, data from the National Family Health Survey(NFHS) conducted in 1998-99 shows that the median age at first birth in the state is 19.0 years while the corresponding figure for India is 20.6 years [IIPS andORC Macro, 2001]. Scheduled Tribes constitute a substantial proportion (26 per cent) of the state’s total population [RGI 2001]. The major tribes in the state are santhal, oraon and munda. A vast majority of tribals reside in rural areas. Tribals largely depend on forest re-sources for food, shelter and medicine. The oraon tribe follows the Sarna religion and worships the sal/teak (sarna) tree, consid-ered the abode of goddess Sarna. It is believed that the goddess protects the community from natural calamities and disasters (Government of Jharkhand web site, www.jharkhand.nic.in). The present health system in Jharkhand is characterised by poor infrastructure, low quality of services and lack of personnel. Maternal and child health services from the private sector are more frequently utilised than those available from the public health system [Mishra and Pan-dey 2000]. Not surprisingly, as data from NFHS-3 (2005-06) indicates, maternal healthcare seek-ing among women in Jharkhand is much lower than the national average. For example, 36 per cent of the mothers in the state had at least three antenatal check-ups for their last birth compared to 51 per cent nationally; likewise, 15 per cent of the mothers in Jharkhand received iron and folic acid supplementation for 90 days, compared to the all-India figure of 22 per cent [IIPS 2007]. Ac-cording to the district-level household survey, 71per cent of the mothers in Jharkhand had re-ceived tetanus toxoid vaccination compared to the all-India figure of 80 per cent [IIPS 2006]. A relatively smaller proportion of births in Jharkhand (19 per cent) took place in a health facility as compared to the national aver-age (41 per cent). In addition, child immunisation coverage in Jharkhand is much below the national average; 56 per cent of children in Jharkhand received some immunisation compared to 80 per cent of children nationally [IIPS 2006].While utilisation of maternal health services is generally low in the state, it is even more limited in the case of the scheduled tribe(ST) population. Data from the NFHS-2 (1998-99) shows that among all castes and groups, the highest percentage of anaemic, who delivered at home, without skilled attendance, tetanus im-munisation and iron folic acid supplements during pregnancy, were from the STs [IIPS andORC Macro 2001]. For example, 41 per cent of tribal women in the state had a body mass index (BMI) below 18.5kg/m2 as compared to 31 per cent of other (scheduled castes (SCs)/other backward castes) women, andover 86 per cent of tribal women in the state were anaemic, compared to 60 per cent of other women. Home deliveries were the highest amongst theSTs (96 per cent compared to 69-88 per cent among any other group). Awareness among tribal women was also comparatively lower: only 5 per cent of tribal women had heard of human immu-nodeficiency virus (HIV) acquired immunodeficiencysyndrome (AIDS) as compared to 35 per cent of otherwomen;and88percent of tribal women were not regularly exposed to mass media as compared to 44 per cent of women form non-SC/other backward caste groups [IIPS andORC Macro 2001].MethodologyData for this paper is drawn from a study of married adolescent tribal girls in Lohardaga district of Jharkhand. Lohardaga is one of the predominantly tribal districts in the state – 56 per cent of the district’s population belongs to STs. A survey of married ado-lescent girls aged 15-19 years was conducted in May-June 2005 in 20 villages in senha commu-nity development block in the district. Respond-ents were identified through a rapid household listing in the study villages, and all eligible mar-ried adolescent girls were invited to participate in the survey. Refusal rates were low; however, in spite of repeated visits, the study team was able to interview only 402 of 460 married adolescent girls identified through the household listing. A structured questionnaire was administered with questions related to knowledge of sexual and reproductive health, maternal and child health behaviours, autonomy including their participa-tion in household decision-making and access to resources, peer/social networks and spousal communication. Findings presented in this paper are based on a sub-sample of 250 women who had reported at least one live birth at the time of the survey. These women were asked to provide information on their maternal healthcare seeking practices during their last pregnancy that resulted in a live birth.
REPRODUCTIVE HEALTHDECEMBER 1, 2007 Economic & Political Weekly58Table 2: Agency and Peer/Social Support among Respondents (N=250)Household decision-making index, mean score 1.3Women with access to money (%) 60.4Women having friends in their marital village (%) 56.8Women who reported spousal communication on family size (%) 57.6Table 3: Awareness of Maternal Health Practices among Respondents (N=250) %Women who perceived antenatal services are important 70.4Women who reported some awareness of steps that make delivery safer 80.4Women who reported some awareness of complications during the post-partum period 84.0Women who reported awareness of the importance of feeding colostrum to newborns 71.6In this paper, we have used a number of outcome variables in-dicating healthcare seeking during pregnancy, delivery and the post-partum period (see the Appendix for a list of variables and operational definitions used). As indicators of healthcare seeking during pregnancy, we have included two categorical variables indicating whether respondents received any antenatal services (that is, antenatal check-ups, iron and folic acid supplementation or tetanus toxoid vaccination), and whether respondents received full antenatal services (that is, at least three antenatal check-ups, at least one tetanus toxoid injection and an adequate amount of iron and folic acid supplemen-tation). As indicators of care seeking dur-ing delivery, three categorical variables were constructed: whether respondents participated in decisions about place of delivery, whether respondents made any arrangements for delivery and whether respondents had an institutional deliv-ery. For post-partum care seeking, we have constructed two variables – one indicating seeking care for the mother in the case of non- institutional delivery, that is whether the respondents had at least one post-partum check-up within two months of delivery, and one indicat-ing care seeking for the newborn, that is whether the newborn received any im-munisation. The explanatory variables considered in the analyses for identifying the cor-relates of maternal healthcare seeking include, apart from typi-cal background characteristics (age, school attendance, socio-economic status of the household, age at marriage), variables re-flecting young women’s autonomy, extent of peer/social support, spousal communication and awareness of appropriate maternal health practices. In analyses pertaining to correlates of institu-tional delivery and post-partum check-up, an additional variable indicating whether respondents received full antenatal services is included. Two indicators measure a young woman’s autonomy – her role in household decision-making and access to money. A young woman’s role in household decision-making is measured by responses to a series of questions on her involvement in decisions about household purchases of items such as food, small gifts, jew-ellery, clothes, livestock and any other expensive item. A score of ‘1’ was assigned if the woman had made purchase decisions about these items herself or participated in joint decision-making with her spouse or other family members and ‘0’ if she had not parti-cipated at all in such decisions. The scores were added to obtain an index ranging from 0-6. To assess a young woman’s access to money, respondents were asked whether anyone gave them mon-ey to spend or manage. The extent of peer/social support received by a young woman is measured by a categorical variable indicat-ing whether the respondent had friends in her marital village. The extent of spousal communication is measured by responses to the question if a woman discussed the number of children she would like to have with her husband. A young woman’s awareness of the importance of maternal health services is measured by her response to a number of ques-tions. While respondents’ perceptions about whether a pregnant woman needs to take iron and folic acid tablets and tetanus tox-oid vaccination during pregnancy are considered in multivariate analysis to identify correlates of receiving antenatal services, their awareness of what makes delivery safe is taken into account in the analy-sis to identify the correlates of delivery care. Likewise, awareness of danger signs during the post-partum period is used in the analysis pertaining to post-partum check-up, and awareness of the importance of feeding colostrum in the analysis pertaining to immunisation of newborns. Multivariate logistic regres-sion is used to identify factors independ-ently associated with the various dimen-sions of maternal health seeking. ResultsSocio-Demographic Profile: The socio-demographic characteristics of respond-ents are summarised in Table 1. As can be seen, 90 per cent of adolescent re-spondents were aged 18-19 years (age range 12-19 years), and four-fifths had never attended school. The majority had married at a young age – the mean age at marriage is 15 years. One-third of the women lived in house-holds with a low standard of living index. Nearly all respondents lived in non-nuclear families. The majority of women followed the tribal Sarna religion and more than three-fourths belonged to the oraon tribe. Women’s Agency and Peer/Social Support: Data on young women’s agency shows that most adolescent girls did not have a say in decisions related to the purchase of various household items (mean score on the decision-making index was 1.3 on a scale ranging from 0-6) (Table 2). However, the vast majority re-ported that other family members gave them money. Similarly, most respondents appear to have fairly good peer/social support – nearly three-fifths reported having friends in their marital village. It is interesting to note that spousal communication is fairly common among the study participants; 58 per cent of respondents reported discussing desired family size with their husbands. Women’s Awareness of Maternal Health Practices: As can be seen from Table 3, awareness of various maternal health prac-tices among the study participants is fairly widespread. More than two-thirds of the respondents perceived that a pregnant woman should take iron and folic acid tablets and tetanus tox-oid injections. Most women – four-fifths – mentioned at least one measure that would make delivery safe, for example, having an Table 4: Maternal Health Seeking Behaviour % NReceived some antenatal services 59.2 250Received full antenatal services 12.0 250Participated in decisions about place of delivery 43.1 248*Made arrangements for delivery 19.0 248*Institutional delivery 7.7 248*Received a post-partum check-up 14.8 229@Sought immunisation for newborn 58.4 245** Data missing for the remaining cases (out of 250).@ Analysis covers only those who reported a non-institutional delivery.
REPRODUCTIVE HEALTHEconomic & Political Weekly DECEMBER 1, 200759Table 5: Correlates of Maternal Healthcare Seeking Antenatal Care Delivery-Related Care Received Sought Any FullParticipatedin MadeInstitutionalPost-partumImmunisation Decisions Regarding Arrangements Delivery Check-up for Newborn Place of Delivery for DeliveryAge .812 .990 1.117 1.718~ 1.235 1.820~ .987Education Never attended ® Attended school 2.334~ 2.115 2.270* 2.576* 2.509~ .923 2.707*Socio-economic status Low® Middle 1.761 .817 2.750** 1.597 1.523 1.653 1.024 High 2.382~ .755 1.239 .715 .791 3.919* 2.375~Age at marriage .903 .848 .909 .842 .775 .654* .871Household decision-making 1.261** 1.047 1.223* 1.094 1.057 .995 1.240*Access to money No® Yes 2.029* .946 1.390 .462~ .493 2.636~ 1.498Having friends in marital village No® Yes 3.589*** .511 3.417*** 1.488 1.965 1.050 2.681**Discussed desired family size with spouse No® Yes 2.519**5.577** 3.122*** 5.474*** 3.718* 4.805** 3.943***Awareness of maternal health services Not aware ® Aware 4.367*** 1.932 5.240** 4.589* 4.996 1.512 .734Received full antenatal services No® Yes – – – .523 4.693** – Observations# 250 250 248 248 248 229 245~ p<.10, * p<.05, ** p<.01, *** p<.001. # Data missing for the remaining cases (out of 250). ® Reference category.Multivariate logistic regressions performed.institutional delivery and identifying a trained birth attendant. Similarly, most women were able to name at least one warning sign of complications that can occur during the post-partum period, for example, heavy bleeding, fever and foul-smelling discharge. More than two-thirds of respondents felt that it is important to feed colostrum to the newborn.Maternal Health Seeking Behaviour: Data indicates that maternal healthcare seeking is very limited among the study participants. While the majority of young women (59 per cent) received some antenatal services like an antenatal check-up, iron and folic acid tablets or tetanus toxoid injections, the proportion of women who received full antenatal services was much lower (12 per cent) (Table 4, p 58). Further, while 26 per cent of ado-lescent mothers reported receiving any antenatal check-up, only 14 per cent received an antenatal check-up in the first trimester and 13 per cent received three or more antenatal check-ups. More than two-thirds (69 per cent) of those who received any antenatal check-up (18 per cent of all women) reported receiv-ing the check-up from private providers. A little less than one-half (47 per cent) of mothers received iron and folic acid tablets and more than one-half (56 per cent) received tetanus toxoid injections. The vast majority of adolescent girls reported that they preferred to deliver at home (90 per cent). While a substantial proportion (43 per cent) had participat-ed in decisions about place of delivery, a relatively smaller proportion (19 per cent) had made arrangements for their delivery; even fewer had delivered in an institution (less than 10 per cent). Among those who delivered at home, only 4 per cent were attended to by health provid-ers and 14 per cent by trained dais (tradi-tional birth attendant).Likewise, seeking post-partum check-ups is not very common among mothers; less than one-fifth of young mothers who had a non-institutional delivery received a post-partum check-up. Those who had a post-partum check-up reported that they received the check-up within two months post-partum, with a median duration of one week. Seeking im-munisation for newborns is relatively common in the study area; nearly three-fifths of young mothers reported that their babies had been immunised. Correlates of Maternal Healthcare Seeking Behaviour: The results of the multivariate analyses show some interesting asso-ciations, though not consistent, across the different dimensions of maternal healthcare seeking considered in this paper. Receiving any antenatal service is found to be positively associated with a number of factors including young women’s auto-nomy, as measured by their role in household decision-making and access to money, peer/social support; spousal communica-tion and perceptions about the importance of antenatal services. As can be seen from Table 5, seeking antenatal services tends to increase with adolescent married girls’ increasing participation in household decision-making (Odds-Ratio 1.261, p<.01). Like-wise, findings indicate that adolescent girls with access to money tend to be more likely to have received some antenatal services than girls with no access to money, even after socio-economic status is controlled (OR 2.029, p<.05). Similarly, girls who reported friends in their marital village are found to be more likely to have received some antenatal services than those with no friends (OR 3.589, p<.001). Findings also show that adolescent girls who reported spousal communication on reproductive health matters are more likely to have received antenatal services than those who reported no such communication (OR 2.519, p<.01). As expected, girls who perceived the importance ofseeking antenatal services are found to be more likely to have received antenatal services (OR 4.367, p<.001) than those who did not perceive such a need. It is surprising that none of these variables, except spousal communication, is found to be signifi-cant when receiving full antenatal services is considered as the outcome indicator, suggesting perhaps that supply-side issues in the study villages might be affecting a young woman’s antenatal care seeking. With respect to delivery care, variables found to be statistically significant differed depending on the dimension of delivery care considered in the analysis. For example, young women’s partici-pation in decisions about place of delivery is found to be positive-ly associated with such factors as school attendance (OR 2.270, p<.05), role in household decision-making (OR 1.223, p<.05), having friends in the marital village (OR 3.417, p<.001), spousal
REPRODUCTIVE HEALTHEconomic & Political Weekly DECEMBER 1, 200761Appendix Table: Variables and OperationalDefinition Used in Logistic RegressionVariables DefinitionDependent variablesAny antenatal service Whether a woman received either any antenatal check-up during pregnancy or iron and folic acid tablet (or syrup) or tetanus toxoid injection during pregnancy. Dichotomous 0= no, 1=yes Full antenatal care Whether a woman received at least three antenatal check-ups, iron and folic acid tablet (or syrup) and tetanus toxoid injection during pregnancy. Dichotomous 0= no, 1=yesParticipation in decision-making regarding place of delivery Dichotomous 0= no, 1=yesMade arrangement for delivery Dichotomous 0= no, 1=yesInstitutional delivery Whether delivery took place at an institution or not. Dichotomous 0= no, 1=yesReceived a post-partum check-up Dichotomous 0= no, 1=yesSought immunisation for the newborn Dichotomous 0= no, 1=yesIndependent variablesCurrent age In years Age at marriage In yearsSchooling Dichotomous 0=never attended school 1=attended schoolSocio-economic status Three categories 1=low, 2=mediumand 3=high depending upon household amenities and assetsDecision-making index Index with values ranging from 0 to 6 indicating the extent to which women have a say in decisions related to various household purchasesAccess to money Dichotomous 0=no access, 1= have some accessHave friends in marital village Dichotomous 0= no, 1=yesInter-spousal discussion on family size Dichotomous 0= no; 1= yesKnowledge about maternal and newborn care a) Knowledge about the need for antenatal care Dichotomous 0= not-needed; 1= needed b) Knowledge about safe labour/delivery Dichotomous 0= Don’t know; 1= have some knowledge c) Knowledge about warning signs of complications during the post-partum period Dichotomous 0 = Don’t know; 1= have some knowledge d) Knowledge about feeding colostrum to the newborn Dichotomous 0=no 1=yesReferencesAmin, R, Y Li and A U Ahmed (1996): ‘Women’s Credit Pro-grammes and Family Planning in Rural Bangladesh’, International Family Planning Perspectives, 22(4), pp 158-62.Basu, A M (1990): ‘Cultural Influences on Healthcare Use: Two Regional Groups in India’, Studies in Family Plan-ning,21(5), pp 275-86.Basu, A M and R Stephenson (2005): ‘Low Levels of Maternal Educationand the Proximate Determinants of Child-hood Mortality: A Little Learning IsNotaDangerous Thing’,Social Science and Medicine, 60, 2011-23.Bhatia, J C (1988): ‘A Study of Maternal Mortality in Anantpur District, Andhra Pradesh, India’, Indian Institute of Management, Bangalore.Bloom, S S, D Wypij and M Das Gupta (2001): ‘Dimensions of Women’s Autonomy and the Influence on Maternal Healthcare Utilisation in a North Indian City’,Demo-graphy, 38(1):67-78.Boulay, M and T W Valente (1999): ‘The Relationship of Social Affiliation and Interpersonal Discussion to Family Planning Knowledge, Attitudes and Practice’, International Family Planning Perspectives, 25(3), pp 112-18, 138.Furuta, M and S Salway (2006): ‘Women’s Position within the Household as a Determinant of Maternal Health-care Use in Nepal’,International Family Planning Perspective, 32(1), pp 17-27. 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Foremost is that the very limited maternal healthcare seek-ing observed in this study clearly calls for a multi-pronged ap-proach to improve maternal healthcare seeking among married adolescent tribal girls. The finding that autonomy significantly influences adolescent mothers’ maternal healthcare seeking clearly underscores the need for efforts to empower married adolescent girls. Programmatic attention to involve husbands and encourage spousal communication is clearly indicated. Equally important are efforts to enhance social networking among married adolescent girls. Community groups of adolescent women can serve as forums for disseminating health-related information and providing services such as ante-natal and post-partum check-ups and immunisation. The study findings also call for efforts to raise awareness about safe moth-erhood practices. Moreover, this study has mainly examined the barriers that hinder women’s utilisation of maternal health services from the demand side perspective; however, what is lacking is information on supply-side bottlenecks, which calls for further study.

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