JOURNAL OF ADOLESCENT HEALTH 1992;13:696-699
INTERNATIONAL SECTION
Health Profile of Pregnant Adolescents Among Selected Tribal Populations in Rajasthan, India VINIT SHARMA, M.D.,
D.H.H.M.,
AND ANURAGINI
Among primitive tribal communities in India, girls are traditionally married immediately after attaining menarche. In the present study all adolescent girls in the second and third trimesters of pregnancy from 15 randomly selected villages of 4 tribal development blocks of Udaipur district (South Rajasthan State, India) were studied* The data were analyzed with reference to parity, anthropometry, anemia, and other dietary deficiencies. A total of 54 adolescent girls (13-19 years of age1 were included in the present study. Of these, 59% (n = 321 were found to be primigravidas, 39% (n = 201were pregnant for the second time, and 2 girls were pregnant for the third time. A majority were illiterate (u = 461, and almost all of them were found to be suffering from moderate-to-severe anaemia (I = 511. Similarly, a large majority (n = 461 had a body mass index (BMI) less than normal and body weight less than 42 kg. Two of the pregnant girls were also found to be suffering from pelIagra, while approximately one-third of the girls had vitamin A deficiency. Only 2 had ever practiced family planning, consisting of some herbal preparations given to them by the folk doctor. Of the study participants, 19 girls (35.0%) were in the third trimester of pregnancy; of these, 7 had evidence of malpresentation or cephalopelvic disproportion. This study highlights the health profile and needs of pregnant adolescents among tribal populations in a dmught-affected area in India. KEY WORDS:
Childhood marriages Adolescent mothers
FromtheDepartment ofCommunity Medicine, P. S. MedicalCollege and &pital, cujamt, India. Addmss Repiint Requests to: Vinit Sharma.. M.D., D.H.H.M., &artmentofCommunity MedicineP. S. MedicalCortegeandHospital, Kmumsud388 325. Gujamt, India. Manrrsrriptaqted March 15.1992. 6%
wo-l39xl92l55.00
SHARMA,
M.B.B.S.
Tribals
Nutritional deficiencies Complications of pregnancy Family planning Traditional methods of contraception Medicosocial interventions. The problem of adolescent pregnancies, which is a relatively recent epidemic in the West, has been a constant, eternal phenomenon in the developing world. In India, in spite of legislation prohibiting marriage of girls before 18 years of age, a large percentage of rural girls are still being married before their 16th birthday. In the case of tribal communities, primitive societies that still lead an isolated existence, girls never experience adolescence. The onset of menarche in traditional, orthodox societies (and especially so in tribal communities) signifies the age of sexual and social maturity of the girl (1). In such societies, children are traditionally married off at any time during their childhood at an age ranging from a few months to a few years. Some parents may even indulge in anticipatory marriages before the birth of their children. After marriage, the female child continues to live with her own parents until the time of her first menstruation, after which she is sent to the house of her inlaws. Consequently, most of the tribal girls, who have an average age of menarche of about 12.3 years (+ 1.6 years) have their first sexual experience- by age 13 years (2), and, by the age of 14 years, most are pregnant. Thereafter, pregnancies follow in quick succession and, by the age of 20 years a tribal girl has usually been pregnant 4 or 5 times. In such societies, pregnancy during adolescent years is considered a normal occurrence, and any deviation thereof is regarded as a sign of infertility or a
8 Society for Adolescent Medicine, 1992 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
December 1992
heavenly curse. Girls who do not bear a child within a few years after menarche are virtual social outcasts (3). Tribal adolescent girls have to bear the burden of early and quick pregnancies coupled with the additional onus of acting as earning members of the family (4,5). Poverty, illiteracy, and ignorance are rampant among the tribals; and, therefore, every working member is a valuable asset for the family. Young pregnant tribal girls, thus, continue to perform hard manual work without respite throughout their Ijregnancy up to the very time of onset of labor pains. Medical care is often not available in the inaccessible and inhospitable geographical terrain where the tribals live (6), and traditional birth attendants and folk doctors are the only recourse at times of complications. The story of a tribal girl in India is, thus, a story of pregnancies, which are too many, too early and too close, and a tragedy of health care which is often too far, too late, and too deficient. The high levels of fertility among tribals are thus balanced by the high incidence of infant and maternal mortality in these societies. For every 1,000 live births, there are 160 infant deaths and 10 maternal deaths per year-approximately twice the national average for India (2,6). In spite of high mortality rates, the growth rate of tribal communities has been 3.2% for the last 10 years, higher than the national growth rate of 2.24% during the same period of time (1,6). The present study was undertaken to study the health profile of pregnant adolescent girls among selected tribal populations, and to analyze the medical problems associated with such pregnancies.
HEALTH PROFILE OF TRIBAL ADOLESCENTS
Data were collected about their age, literacy, parity, anthropometry, anemia, and deficiency of any other dietary factors. All girls were married, as there are no unmarried mothers among tribal communities as a convention and tradition. For anthropometric measurements, weight (kg) and height (m) were taken as per the guidelines provided by the National Institute of Nutrition, India; and the individual body mass index (BMI) was calculated and compared with the guidelines of Indian Council of Medical Research (2). Similarly, hemoglobin estimation was carried out by Sahli’s method and classified as mild, moderate, and severe anemia according to the 1989 guidelines of the World Health Organization (7).
Results Approximately 69% of the pregnant girls were in the age group of 15-17 years (n = 37). Almost all of them were illiterate (n = 46); and those who did have some educational background had only studied at the primary level. Around 60% of the girls (n = 32) were in their first pregnancy, 30% in their second pregnancy, and 2 girls were pregnant for the third tim+both of them having a history of spontaneous abortions during their previous pregnancies; 65% of the girls were in their second trimester, and 35% (tl = 19) were in their last trimester of pregnancy. On the basis of anthropometric measurements (Table l), a majority of the girls could be classified as mild-to-moderately malnourished according to Indian Standards. Similarly, almost all of them were Table 1.
Health Profile of Adolescent Girls
Methods The present study was conducted in the Udaipur district of southern Rajasthan State (India), which has a high concentration of tribal population. Of the 18 community development blocks in the district, 9 are tribal development blocks. By the process of simple random sampling, 4 tribal development blocks were selected for the purpose of this study. A list of all villages in the selected tribal development blocks was obtained; 2nd 4 villages from each of the selected tribal development blocks were chosen randomly to form the sampling frame of the study. Of the 16 tribal villages chosen, one could not be studied because of technical and practical difficulties. In the selected villages all the married, pregnant tribal girls in the age group of 13-19 years, in the second and third trimester of pregnancy, were included.
697
Sample n
%
Anthropometry (BMI) Normal (18.5 or more) Mild malnutrition (17.0-18.4) Moderate malnutrition (16-16.9) Severe malnutrition (less than 16)
8 21 20 5
15 37 37 9
Hemoglobin concentration Normal (12 g/dL or more) Mild anemia (10.0-12 gldL) Moderate anemia (7.0-10 g/dL) Severe anemia (Less than 7.0 gldL)
3 8 29 14
6 15 53 26
Vitamin A deficiency (XN;XIA;XIB) Bitot‘s spots
18
33
Angular stomatitis Pellagra
23 2
43 4
Criterion
BMI, body mass index (weight in kg/height in
m2)
698
SHARMA AND SHARMA
about 26% of them being severely anaemic. l$$teen girls showed evidence of vitamin A deficiency in the form of night blindness or Bitot’s spots. angular stomatitis was also a commonly observed problem among the studied population, and 2 girls also had evidence of pellagra. only 2 of the studied girls had some basic knowledge about modem contraception, i.e., knew about common brand name or market name of a contraceptive and its availablility and method of use. However, only one of them had ever practiced modem contraception herself, whereas the remaining 53 girls or their husbands had never used any modern contraceptive. All of them were familiar with certain traditional or indigenous methods of contraception which are widely used by tribal communities. Adolescent girls included in our study described some traditional or indigenous methods for spacing of births and prevention of conception. The most commonly used method consists of using one-half of a used, partially shelled out piece of lemon, which is inserted deep inside the vaginal canal prior to coitus. The acidic juice of the lemon probably acts as a spermicide while the shell is a primitive version of the cervical cap or diaphragm. Tribal women also practice postcoital vaginal washes or douches by using certain herbs or lime, vinegar, alum, or other solutions diluted with water. The practice of using a primitive version of the vaginal contraceptive sponge made up of old pieces of cloth soaked in some solutions was also observed. Some tribal couples were also found to use certain herbal concoctions routinely, which, they believe, possess some contraceptive and/ or abortificient properties. There were no maternal deaths in the studied population, but 2 infant deaths and 3 stillbirths. One girl, who was in her last trimester at the start ;,f the project, had delivered at home and, on substiuent visit, was found to be suffering from vesico-vaginal fistula and severe perineal tears. Of the study population, 32 girls delivered prematurely and 37 of the infants had a birth weight of less than 2.5 kg; 11% of the girls had malpresentationr; (mostly breech),. as compared with 5% in rural Indian adult wont. (8). Similarly, 18 girls (33%) required caesarian section because of cephalopelvic diaprogortion. This again is much higher then the average for adult women in India (around 22%) (2,5,6). anemic,
with
Discussion ‘&we was a high prevalence of malnutrition in the girls includzd in our study. This observation is in
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 8
accordance with the findings of other workers in different tribal communities in India (1,4,5,9). The problem of malnutrition among tribal girls is manifold and multifactorial, the result of a number of factors, i.e., preference for a male child, neglect and underfeeding of girl children compared with their male counterparts, food taboos and social restrictions for certain food items during pregnancy, and forced food inadequacy during pregnancy. To the tribals, a pregnant girl is most importantly an earning member of the family and, hence, a vital asset. The notion that overfeeding or even proper feeding of the pregnant mother will result in a healthy large baby resulting in prolonged and obstructed labor, has forced the tribals to underfeed pregnant mothers in the anticipation that the child will be a small baby and, thus, easily delivered. The present study suffers from an obvious limitation that the number of girls included in the study was insufficient to enable us to derive any conclusions on the basis of our results alone. We were also unable to obtain comparable data on nonadolescent tribal mothers and measure the changes in the nutritional and hemoglobin status of the adolescent girls, because of practical and technical constraints. The near total absence of contraceptive practices among the studied girls may again be explained by the rampant illiteracy and ignorance about the normal. human reproductive physiology among the girls and their husbands. It has been reported that the practice of modern contraception is virtually nonexistent among tribal communities in India (10,J 3).
References 1. Bhandari Bhagwat. Tribalmarriages and sex relations, 1st ed.
Udaiput, India: Himanshu Publications, 1989. 2. National Institute of Nutrition. Annual Report 1987-88. Hy derabad, India: Indian Council of Medical Research. 3. Chaudhary RH. Social aspects of fertility, 1st ed. New Delhi, India, Vikas Publishing House Pvt. Ltd., 1982. 4. RamalingaswahY P. Tribalwomen and their health-problems. Swasth Hind 1987;31:148. 5. Singh JP, Vyas NN, Mann RS, eds. Tribal women and development. Udaipur, India: MLV Tribal Research and Training Institute, 1985. 6. Indian Society of Health Administrators. Health and development of the tribal people in India-Present status and future directions. Bangalore, India, 1990. 7 World Health Organization (WHO). Preventing and controlling iron deficiency anaemia through primary health care: A guide for health administrators and programme managers. Geneva, WHO, 1989. I.
December 1992
8. National Institute of Nutrition. Annual Report 1988-89. Hyderabad, India: Indian Council of Medical Research. 9. Bardhan K. Women’s work, welfare and status--Forces of tradition and change in India. Econ Polit WeekIy 1985;22:41. 10. Khan ME, Prasad CVS. A comparison of 1970and 1980 survey
HEALTH PROFILE OF TRIBAL ADOLESCENTS
699
findings on family planning in India. Stud Fam Rann 19&35;16:312. 11. Population Research Centre. (India). Fertility, mortality and contraception prevalence in Dangs (Report). Baroda, India: Faculty of Science, 1987.
INTERNATIONAL SECTION
Health Profile of Pregnant Adolescents Among Selected Tribal Populations in Rajasthan, India VINIT SHARMA, M.D.,
D.H.H.M.,
AND ANURAGINI
Among primitive tribal communities in India, girls are traditionally married immediately after attaining menarche. In the present study all adolescent girls in the second and third trimesters of pregnancy from 15 randomly selected villages of 4 tribal development blocks of Udaipur district (South Rajasthan State, India) were studied* The data were analyzed with reference to parity, anthropometry, anemia, and other dietary deficiencies. A total of 54 adolescent girls (13-19 years of age1 were included in the present study. Of these, 59% (n = 321 were found to be primigravidas, 39% (n = 201were pregnant for the second time, and 2 girls were pregnant for the third time. A majority were illiterate (u = 461, and almost all of them were found to be suffering from moderate-to-severe anaemia (I = 511. Similarly, a large majority (n = 461 had a body mass index (BMI) less than normal and body weight less than 42 kg. Two of the pregnant girls were also found to be suffering from pelIagra, while approximately one-third of the girls had vitamin A deficiency. Only 2 had ever practiced family planning, consisting of some herbal preparations given to them by the folk doctor. Of the study participants, 19 girls (35.0%) were in the third trimester of pregnancy; of these, 7 had evidence of malpresentation or cephalopelvic disproportion. This study highlights the health profile and needs of pregnant adolescents among tribal populations in a dmught-affected area in India. KEY WORDS:
Childhood marriages Adolescent mothers
FromtheDepartment ofCommunity Medicine, P. S. MedicalCollege and &pital, cujamt, India. Addmss Repiint Requests to: Vinit Sharma.. M.D., D.H.H.M., &artmentofCommunity MedicineP. S. MedicalCortegeandHospital, Kmumsud388 325. Gujamt, India. Manrrsrriptaqted March 15.1992. 6%
wo-l39xl92l55.00
SHARMA,
M.B.B.S.
Tribals
Nutritional deficiencies Complications of pregnancy Family planning Traditional methods of contraception Medicosocial interventions. The problem of adolescent pregnancies, which is a relatively recent epidemic in the West, has been a constant, eternal phenomenon in the developing world. In India, in spite of legislation prohibiting marriage of girls before 18 years of age, a large percentage of rural girls are still being married before their 16th birthday. In the case of tribal communities, primitive societies that still lead an isolated existence, girls never experience adolescence. The onset of menarche in traditional, orthodox societies (and especially so in tribal communities) signifies the age of sexual and social maturity of the girl (1). In such societies, children are traditionally married off at any time during their childhood at an age ranging from a few months to a few years. Some parents may even indulge in anticipatory marriages before the birth of their children. After marriage, the female child continues to live with her own parents until the time of her first menstruation, after which she is sent to the house of her inlaws. Consequently, most of the tribal girls, who have an average age of menarche of about 12.3 years (+ 1.6 years) have their first sexual experience- by age 13 years (2), and, by the age of 14 years, most are pregnant. Thereafter, pregnancies follow in quick succession and, by the age of 20 years a tribal girl has usually been pregnant 4 or 5 times. In such societies, pregnancy during adolescent years is considered a normal occurrence, and any deviation thereof is regarded as a sign of infertility or a
8 Society for Adolescent Medicine, 1992 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
December 1992
heavenly curse. Girls who do not bear a child within a few years after menarche are virtual social outcasts (3). Tribal adolescent girls have to bear the burden of early and quick pregnancies coupled with the additional onus of acting as earning members of the family (4,5). Poverty, illiteracy, and ignorance are rampant among the tribals; and, therefore, every working member is a valuable asset for the family. Young pregnant tribal girls, thus, continue to perform hard manual work without respite throughout their Ijregnancy up to the very time of onset of labor pains. Medical care is often not available in the inaccessible and inhospitable geographical terrain where the tribals live (6), and traditional birth attendants and folk doctors are the only recourse at times of complications. The story of a tribal girl in India is, thus, a story of pregnancies, which are too many, too early and too close, and a tragedy of health care which is often too far, too late, and too deficient. The high levels of fertility among tribals are thus balanced by the high incidence of infant and maternal mortality in these societies. For every 1,000 live births, there are 160 infant deaths and 10 maternal deaths per year-approximately twice the national average for India (2,6). In spite of high mortality rates, the growth rate of tribal communities has been 3.2% for the last 10 years, higher than the national growth rate of 2.24% during the same period of time (1,6). The present study was undertaken to study the health profile of pregnant adolescent girls among selected tribal populations, and to analyze the medical problems associated with such pregnancies.
HEALTH PROFILE OF TRIBAL ADOLESCENTS
Data were collected about their age, literacy, parity, anthropometry, anemia, and deficiency of any other dietary factors. All girls were married, as there are no unmarried mothers among tribal communities as a convention and tradition. For anthropometric measurements, weight (kg) and height (m) were taken as per the guidelines provided by the National Institute of Nutrition, India; and the individual body mass index (BMI) was calculated and compared with the guidelines of Indian Council of Medical Research (2). Similarly, hemoglobin estimation was carried out by Sahli’s method and classified as mild, moderate, and severe anemia according to the 1989 guidelines of the World Health Organization (7).
Results Approximately 69% of the pregnant girls were in the age group of 15-17 years (n = 37). Almost all of them were illiterate (n = 46); and those who did have some educational background had only studied at the primary level. Around 60% of the girls (n = 32) were in their first pregnancy, 30% in their second pregnancy, and 2 girls were pregnant for the third tim+both of them having a history of spontaneous abortions during their previous pregnancies; 65% of the girls were in their second trimester, and 35% (tl = 19) were in their last trimester of pregnancy. On the basis of anthropometric measurements (Table l), a majority of the girls could be classified as mild-to-moderately malnourished according to Indian Standards. Similarly, almost all of them were Table 1.
Health Profile of Adolescent Girls
Methods The present study was conducted in the Udaipur district of southern Rajasthan State (India), which has a high concentration of tribal population. Of the 18 community development blocks in the district, 9 are tribal development blocks. By the process of simple random sampling, 4 tribal development blocks were selected for the purpose of this study. A list of all villages in the selected tribal development blocks was obtained; 2nd 4 villages from each of the selected tribal development blocks were chosen randomly to form the sampling frame of the study. Of the 16 tribal villages chosen, one could not be studied because of technical and practical difficulties. In the selected villages all the married, pregnant tribal girls in the age group of 13-19 years, in the second and third trimester of pregnancy, were included.
697
Sample n
%
Anthropometry (BMI) Normal (18.5 or more) Mild malnutrition (17.0-18.4) Moderate malnutrition (16-16.9) Severe malnutrition (less than 16)
8 21 20 5
15 37 37 9
Hemoglobin concentration Normal (12 g/dL or more) Mild anemia (10.0-12 gldL) Moderate anemia (7.0-10 g/dL) Severe anemia (Less than 7.0 gldL)
3 8 29 14
6 15 53 26
Vitamin A deficiency (XN;XIA;XIB) Bitot‘s spots
18
33
Angular stomatitis Pellagra
23 2
43 4
Criterion
BMI, body mass index (weight in kg/height in
m2)
698
SHARMA AND SHARMA
about 26% of them being severely anaemic. l$$teen girls showed evidence of vitamin A deficiency in the form of night blindness or Bitot’s spots. angular stomatitis was also a commonly observed problem among the studied population, and 2 girls also had evidence of pellagra. only 2 of the studied girls had some basic knowledge about modem contraception, i.e., knew about common brand name or market name of a contraceptive and its availablility and method of use. However, only one of them had ever practiced modem contraception herself, whereas the remaining 53 girls or their husbands had never used any modern contraceptive. All of them were familiar with certain traditional or indigenous methods of contraception which are widely used by tribal communities. Adolescent girls included in our study described some traditional or indigenous methods for spacing of births and prevention of conception. The most commonly used method consists of using one-half of a used, partially shelled out piece of lemon, which is inserted deep inside the vaginal canal prior to coitus. The acidic juice of the lemon probably acts as a spermicide while the shell is a primitive version of the cervical cap or diaphragm. Tribal women also practice postcoital vaginal washes or douches by using certain herbs or lime, vinegar, alum, or other solutions diluted with water. The practice of using a primitive version of the vaginal contraceptive sponge made up of old pieces of cloth soaked in some solutions was also observed. Some tribal couples were also found to use certain herbal concoctions routinely, which, they believe, possess some contraceptive and/ or abortificient properties. There were no maternal deaths in the studied population, but 2 infant deaths and 3 stillbirths. One girl, who was in her last trimester at the start ;,f the project, had delivered at home and, on substiuent visit, was found to be suffering from vesico-vaginal fistula and severe perineal tears. Of the study population, 32 girls delivered prematurely and 37 of the infants had a birth weight of less than 2.5 kg; 11% of the girls had malpresentationr; (mostly breech),. as compared with 5% in rural Indian adult wont. (8). Similarly, 18 girls (33%) required caesarian section because of cephalopelvic diaprogortion. This again is much higher then the average for adult women in India (around 22%) (2,5,6). anemic,
with
Discussion ‘&we was a high prevalence of malnutrition in the girls includzd in our study. This observation is in
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 8
accordance with the findings of other workers in different tribal communities in India (1,4,5,9). The problem of malnutrition among tribal girls is manifold and multifactorial, the result of a number of factors, i.e., preference for a male child, neglect and underfeeding of girl children compared with their male counterparts, food taboos and social restrictions for certain food items during pregnancy, and forced food inadequacy during pregnancy. To the tribals, a pregnant girl is most importantly an earning member of the family and, hence, a vital asset. The notion that overfeeding or even proper feeding of the pregnant mother will result in a healthy large baby resulting in prolonged and obstructed labor, has forced the tribals to underfeed pregnant mothers in the anticipation that the child will be a small baby and, thus, easily delivered. The present study suffers from an obvious limitation that the number of girls included in the study was insufficient to enable us to derive any conclusions on the basis of our results alone. We were also unable to obtain comparable data on nonadolescent tribal mothers and measure the changes in the nutritional and hemoglobin status of the adolescent girls, because of practical and technical constraints. The near total absence of contraceptive practices among the studied girls may again be explained by the rampant illiteracy and ignorance about the normal. human reproductive physiology among the girls and their husbands. It has been reported that the practice of modern contraception is virtually nonexistent among tribal communities in India (10,J 3).
References 1. Bhandari Bhagwat. Tribalmarriages and sex relations, 1st ed.
Udaiput, India: Himanshu Publications, 1989. 2. National Institute of Nutrition. Annual Report 1987-88. Hy derabad, India: Indian Council of Medical Research. 3. Chaudhary RH. Social aspects of fertility, 1st ed. New Delhi, India, Vikas Publishing House Pvt. Ltd., 1982. 4. RamalingaswahY P. Tribalwomen and their health-problems. Swasth Hind 1987;31:148. 5. Singh JP, Vyas NN, Mann RS, eds. Tribal women and development. Udaipur, India: MLV Tribal Research and Training Institute, 1985. 6. Indian Society of Health Administrators. Health and development of the tribal people in India-Present status and future directions. Bangalore, India, 1990. 7 World Health Organization (WHO). Preventing and controlling iron deficiency anaemia through primary health care: A guide for health administrators and programme managers. Geneva, WHO, 1989. I.
December 1992
8. National Institute of Nutrition. Annual Report 1988-89. Hyderabad, India: Indian Council of Medical Research. 9. Bardhan K. Women’s work, welfare and status--Forces of tradition and change in India. Econ Polit WeekIy 1985;22:41. 10. Khan ME, Prasad CVS. A comparison of 1970and 1980 survey
HEALTH PROFILE OF TRIBAL ADOLESCENTS
699
findings on family planning in India. Stud Fam Rann 19&35;16:312. 11. Population Research Centre. (India). Fertility, mortality and contraception prevalence in Dangs (Report). Baroda, India: Faculty of Science, 1987.
