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Exploring the disparity in reproductive health status between tribal and nontribal women in India.

Introduction

India is often presented as a success story of globalization, free market economy, and democracy where emerging billionaires purchase personal aircraft for their convenience, construct the most expensive dwelling residences in the world, and often surface as the buyer-saviors for failing state-owned industries in other countries. These illustrations of the developing nations and emerging corporations worldwide validate the fact that, with the second largest population, India is one of the fastest growing economies in the world (Pradhan, 2010; Singh & Dahiya, 2010) and has secured its place among the ten most emerging industrialized nations in the world due to its steady growth, mainly in services and manufacturing sectors (Singh & Dahiya, 2010). The gross domestic product (GDP) per capita in India has increased to US$1154, and the nation is one of the most lucrative and emerging consumer and financial markets (Pradhan, 2010). Growing numbers of cities and city dwellers are replacing the traditional rural India and its lifestyles (Sridhar, 2010).

Although India's city skylines are climbing rapidly, the fact that the globalized free market economy nourishes new poverty remains a crucial problem for most of the Indian population. About 42 percent of the total population earns US$1.25 per day, which places them below the international poverty line (United Nations Children's Fund [UNICEF], 2010). Despite a large competent technical workforce with excellent reputation worldwide, India still struggles with high unemployment and poverty. Rapid economic development of India has not benefitted all, and the income gap between rich and poor shows an increasing trend. This is particularly true for the marginalized social class such as tribal populations of India who appear to be dispossessed by the Indian society, resulting in exclusion from the mainstream socioeconomic development process. The next section will describe the social and historical background of the tribal populations with a view to highlight the disparity between the reproductive health status of tribal and nontribal populations.

Social and Historical Context

The disparity in the health status between tribal and nontribal populations of India needs to be understood within the context of the traditional social system that historically excludes these indigenous groups from the mainstream economic development of India. The thousand-year-old caste system has contributed to the marginalization of tribal populations. Caste, inherited from an individual's parents, determines his or her socioeconomic position, occupation, and many other aspects of life. Of four main divisions, the Brahmins, who are entitled to be the priests, scholars, and philosophers, are at the top of the hierarchy, with the Shudras, or the laborers and servants, also known as untouchables, at the bottom. The traditional Hindu caste system excludes the lower castes including the tribals from mainstream society and exploits them in various ways (Mohindra, Haddad, & Narayana, 2006; Padel & Das, 2010; Snaitang, 2004). Their advantageous position within the social structure with privileged access to resources provides the upper castes with more opportunities than the lower castes. Thus, there is an association between socioeconomic position and caste (Mohindra et al., 2006). Tribal communities in such a context are situated in the peripheral or marginal position of the overall Indian socioeconomic stratum. It is, however, noteworthy that not all the tribes in India are Hindu by religion. Contrary to the general assumption, a majority of the tribal populations living the mountainous states such as Manipur, Nagaland, Mizoram, and Meghalaya of northeastern India are Christian (Chaube, 1999). About 75 million of the 84 million tribals are followers of major or dominant religions such as Hinduism, Buddhism, or any sects of their traditional religion including Sarna Dharma, Sari Dharma, and Doni Polo. In addition, it is noteworthy that 1.2 million tribals identify themselves as Muslims and about 8 million as Christians (Bajaj, 2011). However, both Christian and Hindu tribals practice and celebrate many customs and rituals retained from origins predating the Aryan invasion, resulting in the imposition of Aryan social structure and isolation (Chaube, 1999; Mitra, 2008). The indigenous culture was influenced by the Aryan invasion and later by the imposition of the caste system to "judge and classify people within the fixed social hierarchy" (Chaube, 1999, p. 524).

The tribals of India constitute about 8.2 percent of the total population. The majority of the Indian population are nontribals and mainly followers of the Hindu (82.41%) religion (Census of India, 2001). Even though tribals are not perceived as an untouchable lower-caste Hindu population by the mainstream uppercaste Hindus, they are marginalized and considered as backward and primitive jati or caste with a pariah status (Mitra, 2008). This perception however, has resulted in greater marginalization of tribals rather than integration into mainstream society (Mitra, 2008). Regardless of the tribals' perspectives toward caste systems, they are the victims of an imposed oppressive caste-based social structure (Snaitang, 2004).

The increasing disparities in socioeconomic and demographic indicators between tribals and the rest of the population of India demonstrate the peripheral, marginalized, and exploited condition of tribal populations (Mohanty, 2002). Such disparities have been addressed and recognized by the Government of India, and since the nation's independence in 1947 major initiatives have been taken to improve the backward conditions of tribal communities with a view to eliminating their social exclusion and integrating them into the mainstream society. However, these so-called development projects have achieved very limited success so far due to critical "failure to comprehend the distinctive characteristics of the tribal areas and schedule tribes" (Mohanty, 2002, p. 96). Even though the objectives of such projects resonate with the Indian constitutional commitment to protect tribal rights and improve tribals' socioeconomic condition (Mohanty, 2002), it appears that such measures have barely reached their targets. This can be observed in a verdict from the Indian Supreme Court, which stated that

... such a predicament of human being[s] facing the prospects of starvation, death, distress sale of crops, labour and even the children, and the helplessness of those who are unable to organize the minimum basic necessities of life can easily be described as too grim a reality for any kind of detached debate (Patnaik, 2002, p. 91).

The marginal position of tribals is evident from their health and human development indicators, which are lower than India's national average in many aspects (Bala & Thiruselvakumar, 2009; Sarkar, Mishra, Dayal, & Nathan, 2006; Subramanian, Smith, & Subramanyam, 2006). The socioeconomic, education, and nutrition indicators presented in Table 1 below show the disparity between the tribal and nontribal population in India.

Exploitation and marginalization of tribal people have been intensified due to extraction of commercial mineral resources, mainly located in the tribal habitats, to support India's ongoing rapid economic growth. The traditional sustainable and subsistence tribal livelihood is under threat from the flow of global and local capital in the exploitation of their physical environment. The growth-oriented economic development model demands rapid industrialization and promotes mega development projects and mineral resource extraction to accelerate the national production of services and commodities. This economic development model, under the shadow of liberalization, privatization, and globalization, is strongly buttressed by the governments of developing countries (Meher, 2009). India is no exception, and, as in many other developing nations, the outcomes of such a development process have been controversial due to the consequent income inequality between groups and the extreme exploitation of marginal groups. Tribal populations of India are one such victim; they have experienced displacement from their natural habitats and loss of control and access to their resources. Between 1951 and 1990, about 21 million people, 40 percent (about 8.5 million) of whom were tribal, were displaced to accommodate development projects in India (Government of India, 2002; Meher, 2009). Another estimate suggests that the total number of displaced people within the last six decades is as high as 60 million (Mathur, 2008). Because the habitats of many tribal groups are located in the mineral-rich geographical regions, these groups have paid the lion's share of the total cost as the victims of modernizing invaders (Meher, 2009; Padel & Das, 2010). The process of displacement has not always been smooth, and in many cases the victims received minimal compensation and rehabilitative assistance (Blaser, Feit, & McRac, 2004). Growth-oriented economic development in India is taking over the traditional subsistence lifestyle of tribal people and is benefitting the advantaged social class with access to sociopolitical power and resources (Mathur, 2009; Meher, 2009). Such exploitation of tribals' common resources and displacement from their land and homes has resulted in increasing conflict between ecosystem-dependent tribals and the elites of the Indian society (Meher, 2009).

Tribal response to the exploitation and marginalization has ignited severe social unrest and protest, primarily in the affected regions (Meher, 2009). Six-decade-long exploitation has fostered the socioeconomic context of the extreme leftist movement in the tribally dominated states in India. Regions located in the eastern part of India are now known as the red corridor to symbolize the dominance of Communist influence in the region. The significance of geopolitical unrest in the tribal regions is indicated in an assessment by former Indian prime minister Manmohan Singh, who singled out the emergence of "Maoist insurgency" as the "biggest internal security threat to India" (Thotam, 2010). Increases in militancy and growth of the Maoist movement in the tribally dominated localities indicated the involvement of the tribal population in so-called insurgency. But how did the tribal communities with minimal education and resources pose the biggest threat to the largest democracy in the world? Nobel laureate economist Amartya Sen pointed out the lack of social justice as the reason behind such violent response (Sakhuja, 2010). Sen argued that tribally dominated areas are "sidelined by the country's development agenda" and underscored such disregard as the possible reason behind insurgency:

Neglect of tribals is a huge spot on India's pursuit of justice. I very much rebel against the view saying we ought to do something about it otherwise they would join the Naxalites. The reason we should do something about them is precisely because it's [a] matter of justice (Sakhuja, 2010).

Singh's comment that referred to the Maoist rebels as the "biggest threat" indicates the dichotomy in the perspective toward this marginal population, reflected in Sen's emphasis on injustice illustrating the contrast between concern for injustice and concern for government sponsorship of such injustice. Such exploitation often has been committed and sometimes deliberately designed by both the public and private agencies. There are numerous examples of state government initiatives for acquiring land from the tribal residents to set up mining industries or industrial projects (Meher, 2009). Such initiatives are often endorsed by the policy framework formulated under the central government's economic development model, focusing on modernization of the manufacturing and industrial sector to result in increased demand for energy and consumption of commodities. This modernization process of production requires raw materials from mines such as aluminum and iron. In the end, this colossal mining industry kicks off invasions in tribal habitats, often accomplished by the local government and/or powerful corporations. The result is obvious; the marginal tribals are left with very few options other than to leave their homes and land. Eminent Man Booker prize-winning author, Arundhati Roy (2010) captured the experience of exploitation and exclusion of marginal populations:
   Almost from the moment India became a sovereign nation, it turned
   into a colonial power, annexing territory, waging war. It has never
   hesitated to use military interventions to address political
   problems--Kashmir, Hyderabad, Goa, Nagaland, Manipur, Telangana,
   Assam, Punjab, the Naxalite uprising in West Bengal, Bihar, Andhra
   Pradesh and now across the tribal areas of Central India. Tens of
   thousands have been killed with impunity, hundreds of thousands
   tortured. All of this behind the benign mask of democracy.


Questions can be raised as to why India, as the largest democracy in the world, failed to ensure the rights of the marginal population. Inquiry should also be made as to the effects of the exemplary Indian economic growth on the lives of these disadvantaged population groups. From a social work perspective, the issue of social justice and equality leads us to examine the situation of tribals' lives. Social exclusion and marginalization of the tribal populations of India raise a significant question: how are the deprived and disadvantaged tribal communities coping within such adverse effects of development? The destruction of land and environment experienced by Native American populations in the United States represents a similar scenario that marginalized this population. However, with a view to survival and saving the environment, examples of forming alliances with former oppressors can be seen as a coping strategy (Else & Hamilton,1980). Do the Indian tribal populations have a similar supportive experience?

In response, it can be speculated that marginalization of these populations is continuing, resulting in a huge disparity between the mainstream and tribal populations. Inequality remains evident in income, education, quality of life, and particularly in health; this is reflected in the disparities in relevant indicators endorsing the fact that tribal populations of India fall considerably behind the nontribal population. Table 2 presents the disparity in health indicators between tribal and nontribal populations.

The poor health condition of the Indian tribal populations is reflected more prominently in the status of their women's reproductive health, which correlates with the social and economic conditions of individuals and households (Middleberg, 2003). The reproductive role of women all through the process of gestation, birth, breast-feeding, and child rearing places them at the focal point of a population's reproductive health (Shankar & Thamilarasan, 2003). Moreover, women are central to various social and economic activities in tribal communities requiring reciprocal interactions with the contributing factors of reproductive health.

The significance of studying tribal populations' reproductive health should be realized in the light of the basic definition of reproductive health, which encompasses the reproductive processes, functions, and systems at all stages of human life (United Nations Population Information Network, 2010). The United Nations (1995, p. 2) defines reproductive health as "a state of complete physical, mental and social well-being, and not merely the absence of reproductive disease or infirmity, in all matters relating to the reproductive system and to its functions and processes." The intrinsic attribute of the definition of reproductive health emphasizes the right of individuals of both genders to be informed about healthy reproductive practice and process, such as knowledge on safe, effective, affordable, and acceptable methods for regulation of fertility and men's and women's access to appropriate health care services to enjoy such rights (Sunil & Pillai, 2010).

Reproductive health is associated with a wide range of issues including the sexual health of an individual or of a community, the condition of the environment where the reproduction takes place, and the collaborative and reciprocal relationship between human and environment. Reproductive health also can be explained as an indicator of the state of social justice, human rights, and empowerment of the tribal population central to social work values (Sunil & Pillai, 2010). These three characteristics are related to the two core components of sustainability, namely, social development and intergenerational equity transfer (World Commission on Environment and Development [WCED], 1987). Social development focuses on building the basic capacity of individuals, groups, and communities and addresses very fundamental values of social work such as human dignity and right to self-determination.

The reproductive health of tribal populations depends on their ability to access ecological resources and their capacity to participate in social and economic institutions (Pillai & Wang, 1999). The sociopolitical power held by the tribal populations in Indian society determines the level of human rights, self-determination, and access to socioeconomic and ecological resources they enjoy. This is particularly true for the ecological resources that influence the reproductive health of tribal population directly. For instance, women's health is highly correlated with the availability of adequate food and nutrition, which depends on the tribal population's access to forestland. However, because of the institutional policy framework, such as Indian forest policy, tribal groups may experience limited access to such traditional common resources, resulting in declines in reproductive health status. Women's access to power and resources emerged as the important contributing factor to their reproductive health at the Fourth World Conference on Women in 1995 held in Beijing that emphasized increasing women's economic and educational status, and as a consequence, women's reproductive rights (Pillai & Wang, 1999). Thus, reproductive health indicates the level of self-determination, women's reproductive rights, and strength of tribals' sociopolitical power.

The state of social justice is also linked to the status of reproductive health of the Indian tribal population. Such linkage is substantiated by the social justice principle, which demands an egalitarian perspective from social workers with a view to ensuring clients' rights to meet basic needs and to have opportunities for their reproductive well-being. Tribals' rights to transfer their resources and indigenous knowledge are central to the sustainability that ensures well-being for the current and future generations. Hence, the status of tribals' reproductive health reflects the extent to which these populations enjoy the human right to maximize their opportunity to enhance reproduction in a secured environment. From a social work perspective empowerment refers to the tribal population's ability to participate in decision making with regard to reproductive decisions and to utilize its own strength and resources to continue or sustain reproduction. The peripheral position of the tribal community in Indian society restricts tribals' access to socioeconomic institutions and resources influencing their level of empowerment.

The above discussion illustrates the robust influence of sustainability that is embedded in the framework of reproductive health. The basic definition of sustainability emphasizes the transfer of intergenerational equity while continuing socioeconomic development without neglecting social justice and violating human rights (WCED, 1987). Since its emergence, social work as a profession and as a discipline has promoted these values and principles and has invested its knowledge and resources in caring and helping individuals and communities to protect their rights and uphold social justice. Moreover, against the backdrop of human-made environmental crisis, the social work profession is strongly embracing the sustainability paradigm.

In such a context, studies on the reproductive health of a marginalized community require an alternative view to incorporate the ecological approach to sustainability, which views the environment as "a dynamic outcome resulting from interaction among all elements that populate the environment" (Pillai & Gupta, 2015).

The next section of this article will attempt to expose the factors that cause the disparity between the reproductive health of tribal women and that of the mainstream population of India. These factors were identified by reviewing the relevant literature on tribal women's reproductive health, including peer-reviewed articles, relevant books and book chapters, and articles from recognized news sources. Literature searches for this study were conducted on several electronic databases including Academic Search Complete hosted by EBSCO, Social Work Abstracts, PubMed, the Social Science Citation Index, Social Service Abstracts, Sociological Abstracts, and Google Scholar. Websites of several development organizations and think tanks such as India Human Development Survey, the World Health Organization (WHO), Demographic and Health Surveys (DHS), the United Nations Development Program (UNDP), and the World Bank were also searched. The key words used in the search included health, reproductive health, tribals of India, sustainability, ecosystem, social development, economic development, social factors, economic factors, reproductive health in India, indigenous populations, and developing countries.

Distinct geographical, environmental, and sociocultural contexts of Indian tribal groups require specific research strategies for each group. This may limit our ability to generalize the findings with respect to reproductive health. Studies on tribal health usually address health problems of a selected tribe from a distinct region and environment (Chakravarty, Palit, Desai, & Raha, 2005; Gautam & Jyoti, 2005; Kshatriya & Basu, 2005; Pati, 2002). It should be noted that the blurring definition of tribal draws a very thin demarcation line between the tribal groups at different levels of assimilation with mainstream society. The Indian government recognizes approximately 700 ethnic groups as scheduled tribes (Ministry of Tribal Affairs, 2004) having a distinct community based on the criteria of (a) occupying a specific geographical area, (b) having a distinct culture featuring a tribal way of life, (c) being engaged in a primitive livelihood or occupation, and, (d) lacking education and techno-economic development (Dash & Pati, 2002). Most of the studies were found to use this definition of tribal populations despite its existing shortcoming in terms of its inability to identify the different levels of assimilation of tribal populations (some Indian tribes are in the advanced stages of assimilation and other tribes are identified as primitive because of their backwardness). However, focusing on assimilation levels to define tribes may be problematic as well; for instance, tribes in an advanced level of assimilation may not be counted as tribes because they do not meet the requirement of being engaged in a primitive livelihood or occupations, even though a particular tribe may have a distinct culture featuring a tribal way of life. Hence, anthropological attributes should be emphasized rather than the abovementioned criteria in identifying tribal populations. With a narrow perspective, studies on tribal reproductive health predominantly emphasized the tribal populations' maternal health and failed to conceptualize reproductive health from a holistic perspective. There are studies on tribal women focusing on sociocultural correlates of health; however, reproductive health has been mostly viewed through the lens of morbidity (Reddamma, Reddy, & Rani, 2002), fertility (Mohanty, 2003), mortality of mother and children (Baruah, 2003; Pati, 2003a), and health and hygiene practice (Biswas & Kapoor, 2005; Chowdhuri, 2005; Dash, 1986; Kshatriya & Basu, 2005; Pandey, 2002; Pati, 2002). Another common shortcoming in the studies on tribal populations' reproductive health is the lack of theoretical explanation of the phenomenon. Without substantial theoretical input, most of these studies did not test a specific hypothesis or research question. Only a couple of studies were found with limited implications from a theoretical or conceptual framework to define tribal populations' reproductive health and to assess tribal women's fertility, their social status, their knowledge of family planning, their level of contraceptive use, as well as a few sociocultural factors (Pati, 2003b; Upadhyay, 2005).

In general prior studies share the methodological limitation of sampling. Most of the sample populations were selected on the basis of accessibility and availability (Nembiakkim, 2008), resulting in a critical threat to generalizability of the research findings. In conclusion, existing studies on tribal populations' reproductive and overall health are informative and can be used effectively for assessment purposes, but they are not explanatory in nature. The next section of this article will discuss the various factors correlated with reproductive health for tribal women in India on the basis of findings from prior literature.

Reproductive Health Factors

The identified factors related to reproductive health can be divided into economic, social, and ecological groups. Prior literature suggests strong associations between reproductive health and gender equality, women's empowerment, and socioeconomic conditions.

Economic Factors

Economic factors influence reproductive health in several ways. Economic development and income both account for improving the reproductive health of women by influencing their reproductive behaviors at both micro and macro levels. At the macro level, economic development of a community can facilitate improved reproductive facilities and services. At the micro level, higher income can provide more resources for women to access health care services. The major identified economic factors correlated with tribal women's reproductive health are discussed in the following section.

The distinct feature of women's higher status in the tribal community than in the mainstream society strongly endorses the fact that women's participation in economic activities, reflected in the labor force composition in terms of gender, is higher than that in the nontribal general population in India (Maharatna, 2005; Shankar & Thamilarasan, 2003). Tribal women participate in various economic activities in addition to regular household responsibilities such as childbearing, cooking, and chores. Participation in the workforce determines employment status, which strongly influences women's reproductive health (Sunil & Pillai, 2010; United Nations, 1987) because such status provides women with income and earning opportunities that empower them to have control over reproductive decisions. However, the extent of women's participation in the labor force varies with the ecological setting of the tribe, which defines the diverse categories of occupations for women, such as food gathering, hunting, jhum cultivating, farming, cattle herding, and wage labor (Basu, 2000). Even though a tribe can be associated with a special occupational skill, its members may have different trades and livelihoods (Debbarma, 2005; Gautam & Jyoti, 2005; Kshatriya & Basu, 2005). Tribal women's occupations often require high nutritional input to support hard labor for long hours. The varied pattern of tribal women's occupations, along with the influence of mediating factors such as nutrition, can strongly affect their reproductive health. For example, women living in a food gatherer tribe require more nutritional input to attain a satisfactory reproductive health than women living in a hunter tribe where women are likely to participate in household and child-rearing activities only. Mediating factors such as deforestation and environmental degradation have caused many tribal groups to shift from traditional occupations (Mitra, 2008), influencing their reproductive behavior and performance.

Another important factor that robustly influences tribal women's reproductive health is the family structure. Studies have reported a strong correlation between women's fertility and type of family structure (Davis & Blake, 1956; Paydarfar, 1987; Stycos, 1958). Davis (1955) underscored the socioeconomic solidarity of extended family, which stimulates early childbearing and fertility of women. While reviewing the studies on family types and fertility in Bangladesh, India, and Taiwan, Nag (1975) observed lower fertility in women living in extended or joint families compared to that of women living in nuclear families. On the other hand, Upadhyay (2005) noted that living in a joint family might be a reason for a higher level of sexual abstinence that might adversely affect fertility and the likelihood of pregnancy. Hence, in the tribal context, family structure is a strong economic factor affecting reproductive health because the size of the family determines the workload of a woman living in the family. Compared to small or nuclear families, large families have greater economic advantage, leading to their greater ability to invest in the health of their members including the women.

The structure of the family is shaped by the social organization of a tribe, which is based on the descent groups, generally known as the clan, which consist of members who have a common ancestor. Even though the most common descent group among Indian tribal populations is the extended family, studies have reported the prevalence of nuclear-type families among the tribes as well (Debbarma, 2005; Kshatriya & Basu, 2005; Pandey, 2002). Availability of many essential inputs for reproductive health, such as nutrition, may vary according to the family size within the same tribe.

There are correlates of health that influence the economic factors through their effects on the family's economic capacity to spend for health care such as life expectancy, birth intervals, and age of marriage and birth of first child. These health correlates have a robust effect on maternal mortality, fertility, total number of pregnancies, and accessibility to and quality of maternal health care (Menard, 1987; Middleberg, 2003; Zhang & Zhang, 2005).

Tribal populations' perspectives on their health status influence their health and hygiene practice, which is strongly shaped by their sociocultural beliefs and customs. For instance, women of many tribes continue their regular hard-working economic activities during advanced stages of pregnancy (Basu, 1993); such a practice, which is endorsed by tribal custom as normal, may also prevail during the postnatal period, which can adversely affect the health of newborn children. Tribals' perception of their health status in general is not very good, which, from the tribals' point of view, resulted from lack of access to nutrition and health care (Mohanty, 2002; Roy Burman, 1986). Because of the strong association between being well and increased capability of an individual, self-perception of the health condition is an economic factor correlated with reproductive health.

Poverty-stricken tribal groups and tribal women of India (Beck & Mishra, 2011; Ministry of Tribal Affairs, 2004; Planning Commission of India, 2008) have very limited access to resources and institutional support. In the backdrop of the well-established link between poverty and vulnerable health conditions (Das Gupta & Chen, 1996; Mohindra, 2009), the reproductive health of tribal women can be influenced by the institutional input of pro-poor health strategies such as microcredit schemes. Tribal women's access to such schemes would increase their abilities to remain healthy, and good health would result in the economic well-being of the individuals and families and hence in increased reproductive health (Mohindra, 2009; Mohindra & Haddad, 2005; Mohindra et al., 2006). As a macroeconomic correlate, access to institutional support strongly influences tribal women's reproductive health.

Social Factors

Certain social and cultural customs, values, and practices are unique to tribal populations of India. They are diverse but have a common ground of harmony with nature and its utilization to maintain health and hygiene. Several social factors have been reported as correlates with tribal women's reproductive health such as women's marriage practices (Chakravarty et al., 2005), education, social status (Mann, 1996; Sikdar, 2009), and health and hygiene practices (Ali, 1994; Chaudhuri, 1994), which will be discussed in the section below.

The cultural norm of marriage practice has a robust effect on the reproductive health of tribal women. Customs of marriage vary among tribes and influence several factors of women's reproductive health such as age at marriage, pattern of family organization, women's status in society, and women's decision-making ability (Kshatriya, 1992). Tribal marriage broadly can be categorized as (a) endogamy, (b) exogamy, or (c) consanguineous patterns (Basu, 1995). In addition, cross-cousin marriage is practiced in many tribal societies (Basu, 1995). Each of these marriage practices may influence the reproductive health in a distinct way; for instance, consanguineous marriage can lead to increased miscarriages, stillbirths, neonatal deaths, and physical and mental defects (Basu, 1993, 1995).

Marriage practices also define whether a woman is in a polygamous or monogamous relationship. Several Himalayan tribes such as the Naga and Lusia practice polygamy, mainly for the economic reason of having enough labor for agricultural activities (Basu, 1995). By contrast, many tribes such as the Jausaris and Todas used to practice polyandry (Basu, 1995), and there are many tribes who strictly practice monogamous marriage such as the Lodhas of West Bengal (Chakravarty et al., 2005). Such marriage practices strongly shape the family and social structure, the division of labor within the group, and women's status and decisionmaking ability, which in turn influence women's reproductive health.

Age at first marriage is a crucial factor of tribal marriage practice. It should be noted here that tribal women's age at marriage does not always reflect their age at entry to sexual union, since, unlike nontribal Indian society, virginity is not crucially valued by many tribal groups (Vidyarthi & Rai, 1977). Usually, tribal girls are married off at a mature age compared to the age of nontribal women; however, the influence of mainstream Hindu society is changing this trend (Sinha, 1986). The average age at marriage for tribal women was found to be higher (16.39) than that of the nontribal rural women (15.39) in the Indian Census of 1971 (Basu, 1995). However, age at marriage varies across the tribal groups in India. Tribal women from the northeastern region of India are older at marriage than the tribals in the central and southern regions (Sinha, 1986). Age at marriage directly influences the reproductive health of tribal women by determining the age of entry into sexual union/intercourse, which is a strong determinant of fertility. Marriage at a younger age increases the risk of abortions, miscarriages, maternal mortality, and stillbirths (Basu, 1995). Delayed marriage or marriage at maturity may contribute to women's higher level of economic and educational attainment, which in turn can influence their reproductive health.

Women's education is strongly correlated with several indicators of reproductive health such as contraceptive use (Martin, 1995; United Nations, 1987), exposure to sexual intercourse (Cleland & Rodriguez, 1988; Cochran & Farid, 1989; Sunil & Pillai, 2010), age at first menstruation (Sunil & Pillai, 2010), and decision-making power (Bawah, 2002; Cleland & Rodriguez, 1988). Particularly in the tribal context with limited health care resources, the level of education of the mother is a strong correlate of infant mortality (Basu, 1995). In general, literacy among the tribal populations is very low (Basu, 1995). The Primary Census Abstract of India shows a notable difference in the female literacy rate between the tribal (14.50%) and nontribal (39.29%) or general population in India in 1991 (Shankar & Thamilarsan, 2003). Moreover, the level of education and literacy among tribal populations varies. The literacy level of women not only influences their reproductive performance, but it also affects their income and consequently other factors of reproductive health such as health-seeking behavior, health and hygiene practice, and age at first marriage.

The reproductive health of tribal women is highly dependent on the gender hierarchy of the tribe, which infrequently, unlike mainstream Indian society, accords women with higher status than men, particularly in a matriarchal society (Basu, 1995; Sikdar, 2009). Tribal societies in India generally are patriarchal (Basu, 1995; Zaman, 2008), but there are a few matrilineal tribal groups such as the Khasi, Garo, Jaintia, Lalung, and Rabha of Northeastern India (Mann, 1996; Sikdar, 2009). Even in patriarchal tribal societies, women enjoy relatively more freedom and higher status than the women in nontribal societies. However, the overall status of tribal men is higher than that of tribal women, and change in the status of women leading to inferior positions in tribal societies has been underscored in several studies (Chauhan, 1990; Mann, 1996). It can be predicted that tribal women's experience of living in a patriarchal or matriarchal society will influence whether or to what extent they have control over reproductive decision making, earnings, sexuality, and other reproductive behavior related to fertility.

The status of women in a society is strongly influenced by the dominant social values and societal gender perspective. The traditional privileged position or status of tribal women within groups is going through change, which is reflected in the shifting trend in Indian tribal societies from the matrilineal system to the patrilineal system and often from polyandry to monogamy practice (Mann, 1996). Therefore, the status of women should not be taken for granted in the tribal context, particularly against the backdrop of a declining gender ratio, which dropped from 987 to 972 females per thousand males within the three decades from 1961 to1991 (Basu, 1995). The gender ratio suggests to what extent the females are treated equally to males in a human population; therefore, a higher gender ratio indicates higher status of women and the presence of social and culture values protecting women's interests. The status of women also correlates with women's economic power, opportunity for education, access to community resources and networks, and most importantly, reproductive decision-making power (Das Gupta & Chen, 1996; Mohindra, 2009; Sunil & Pillai, 2010). All these factors can influence the reproductive health of tribal women.

Reproductive health strongly correlates with health and hygiene practices of tribal populations including supernatural beliefs related to illness and treatment, the strong role of traditional medicine men or shamans, community involvement in disease control and treatment, and mixed interventions of traditional and modern health care (Chaudhuri, 1994). Social values, traditional knowledge, religious beliefs, material culture (e.g., tools and techniques), and social organization contribute to this traditional system (Ali, 1994). The ecosystem and surrounding environmental or physical setting are strongly linked with the traditional system of tribal hygiene (Chaudhuri, 1994; Khera, 1994). It is important to underscore the strong role of community as a collective unit in health practices (Ali, 1994; Chaudhuri, 1994). Tribal health and hygiene practice emphasizes holistic cure of a disease comprising physical, psychological, and spiritual well-being. Unlike modern-day doctors, tribal shamans and medicine men provide the patient with spiritual and mental support along with the remedies for physical illness. The relationship between a tribal woman and traditional health care is based on trust, responsibility, charity, power, and respect, from which she expects more than skill-based interventions as treatment (Ali, 1994). The presence of supernatural entities is dominant in tribal health and hygiene practice, which defines disease as a consequence of supernatural, human, or natural power (Ali, 1994; Chaudhuri, 1994; Dash, 1986; Gupta, 1986). Such beliefs emphasize the spiritual aspect of prevention rather than maintaining a clean and hygienic sanitary living condition (Ali, 1994). Traditional tribal socioreligious practices, such as alcohol consumption during pregnancy, can adversely affect women's reproductive health as well as the tribal population's general health. Tribal hygiene practices can impose a taboo on crucial determinants of reproductive health such as food habits and diet. For instance, the Birhor tribe of West Bengal views food as an agent of disease and restricts taking ingredients essential for nutrition such as salt until at least three days after childbirth (Bhattacharya & Sengupta, 1986). Negligence in special maternal and child health care has been observed as a common practice among the Kutia Kondh, Santal, Jaunsari, and Kharia tribal groups (Basu, Jindal, & Kshatriya, 1990). In conclusion, health and hygiene practice appears to be a strong social factor in tribal women's reproductive health.

Ecological Factors

Ecological factors highly influence tribal women's reproductive health (Chaudhuri, 1994). The relationship is based on a reciprocal interaction and interdependence between tribals and their natural habitat. Environmental factors of reproductive health encompass the functionalities of other subsystems of the tribal health system. The tribal health system is a comprehensive natural system that uses inputs from surrounding ecology in order to maintain the sound biopsychosocial health of the tribal populations that is required for survival in the wild. The forest-based tribal health system works as the powerhouse, providing these populations with nutrition, cure, and care that eventually build the human capital of which woman is the essential part. Women play a vital role in the forest-based economy where they collect food, fuel, medicine, and housing material from the forest and participate in forest-dependent cultivation and animal husbandry (Dash & Pati, 2002; Menon, 1988).

This strong correlation between ecology and the reproductive health of women is manifested by the fact that the nutritional needs of tribal populations as well as tribal women are primarily met from the proximate ecology, which is currently at risk due to deforestation and environmental degradation (Ali, 1980; Menon, 1988; Patel, 1985). This may be a factor in the malnutrition or undernutrition of tribal populations of India in general (Basu, 1995; Beck & Mishra, 2011; Tandon, 1994).

It is noteworthy that the nutrition status of tribal populations in India, which varies from tribe to tribe, is in general less than satisfactory. The tribal woman's diet has been reported as being deficient in calcium, vitamin A, riboflavin, and animal protein (Basu, 1995; Rizvi, 1986). The most common disease that tribal women experience from malnutrition is anemia (Basu, 1995; Gupta, Gupta, Zafar, Mangal, & Sharma, 1983; Pati, 2002; Reddamma et al., 2002), which may affect the reproductive health of women very adversely by lowering their resistance to fatigue and their energy for work and by increasing vulnerability to other diseases. The other reported prevalent diseases among tribal women are pyrexia, respiratory complaints, gastrointestinal diseases, rheumatic diseases, and gynecological problems (Basu, 1995; Gopalan, 1987). As the primary source of food and nutrition, the surrounding ecology in which the tribes live becomes instrumental in the reproductive performance of tribal women, particularly pregnant women whose level of nutrition is a vital determinant of the fetus's growth and chances of survival. Tribal sociocultural norms and values and health practices also contribute to women's nutritional deficiency (Basu, 1995; Basu et al., 1990). For instance, in many tribes, women do not take special or extra food while they continue their daily hard work during pregnancy (Rizvi, 1986), resulting in reduced body weight and low levels of hemoglobin that can lead to maternal mortality (Basu, 1995). In the male-dominant traditional patriarchal tribal groups, women living in joint families may be deprived of adequate nutrition because of the social custom that limits the women's food intake by giving preference to the male members of the family.

Traditional tribal health practice is largely shaped by the symbiotic relationship between the tribes and nature, which has developed the knowledge base of their traditional health care. Environment strongly influences (directly and indirectly) the reproductive health of tribal women through socioeconomic factors. For example, tribal fertility differs between two clans of the same tribe residing in two different terrains due to a spatial variation in economic, sociocultural, and ecological factors (Maharatna, 2005).

Physical proximity to nearby settlement is one factor that influences the extent of contact with mainstream society and affects the tribe's level of assimilation. In 1961, the Dhebar Commission identified four categories among Indian tribal populations in terms of their level of assimilation with mainstream society and the level of adopting a nontribal lifestyle (Basu, 2000). According to the Dhebar Commission, the most assimilated tribal groups were identified as the acculturated tribals who had adopted a nearly modern lifestyle and had traveled far from their original habitat (Basu, 2000). The least assimilated tribal groups, placed in the primitive group category, were at a very underdeveloped stage and were leading a very isolated nomadic life (Basu, 2000). With respect to tribal women's reproductive health, physical proximity to a nearby human settlement (that is, mainstream community) is vital because it determines the extent of tribals' access to modern health care that can strongly influence the status of their reproductive health. Proximity also denotes the level of sociocultural influence of the dominant culture upon tribals' culture. For example, influence of the patriarchal Hindu dominant culture may contribute to downgrading the status of tribal women, affecting their reproductive health.

In addition to the social, economic, and ecological factors that contribute to tribal women's reproductive health, the significance of distinct tribal culture should be noted. This culture forms a strong tribal identity and strengthens social cohesion among the members of the tribes, which makes them unique and sustains the tradition of health practice, societal attitudes toward women, food habits, modes of production, and social organization. Tribal culture nurtures solidarity and tradition; therefore, the strength of the tribal culture indicates whether or to what extent the tribe will survive with its own ethnic identity. However, the survival of tribal culture depends on the condition of the surrounding ecology, which provides tribes with the sense of right and access to their territory, food security, and sound physical and psychological health. India's rapid economic growth may appear as a threat to the tribal population's habitat and ecology because of the increasing demand for minerals by the industrial sector, requiring exploration of mines that are mostly located in the tribal regions (Padel & Das, 2010).

As a concluding remark, it should be noted that prior studies on reproductive health have predominantly looked into the reproductive health of tribal populations from a demographical, anthropological, or medical point of view. These studies in general have focused on the causes and factors of reproductive performance. Moreover, attempts have been made to gather information on diseases, health, and hygiene practices among tribal peoples with special reference to reproductive health. However, the role of the environment in reproductive health as an integral component of the system of reproduction has been overlooked. With a view to fill this gap, the current study takes a holistic approach to explain reproductive health as the outcome of economical, social, and ecological factors. Even though the social work perspective emphasizes the influences of multiple factors on client systems at micro, mezzo, or macro levels, reproductive health has not been examined from an ecological point of view. Despite the emphasis on person in environment (PIE) within the social work theory base, very few studies have conducted empirical tests to measure the influence of environment on a particular community's reproductive health.

This study attempts to capture the embedded similarities between sustainability and social work approach that are yet to be explored. Recognizable similarities between these two approaches can be characterized by the shared goal of rehabilitating, restoring, and maintaining client systems at a satisfactory level of functioning (Pillai & Gupta, 2015). Despite such similar characteristics, the sustainability approach has yet to be established within social work scholarship. Social work's commitment to sustainability is captured in the Brundtland Commission Report (WCED, 1987, p. 49), which stated that "our inability to promote the common interest in sustainable development is often a product of the relative neglect of economic and social justice." The Brundtland Commission Report strongly suggested social justice as a core principle of this discipline for achieving sustainability.

Even though the sustainability paradigm emerged in the contemporary period, the building blocks of this new paradigm preexisted within social work, most likely with different labels. Social work as a discipline needs to adopt this emerging concept in the context of global climate change and environmental degradation. This current study can bridge the gap between these two collaborative aspects to some extent.

Mashooq Salehin, PhD, is assistant professor of Social Work, Radford University, Radford, VA.

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Table 1 Selected Socioeconomic and Nutrition Indicators for
Tribal and Nontribal Populations

Indicator                     Tribal          Nontribal/national

Poverty headcount index (a)   43.8% (2005)    27.5% (2005)
Literacy rate (b)             58.96% (2011)   72.99% (2011)
Employment status (c)
Male (1991)                   53.7%           51.0%
Female (1991)                 30.0%           16.0%
Nutrition status (d)
Underweight (women)           46.6%           33.0%
Anemia (women)                69.2%           56.2%

(a) Estimates based on the consumption expenditure survey of
the Indian National Sample Survey (2004-05), 61st round
(National Sample Survey Office, 2006).

(b) Indian Ministry of Tribal Affairs (2012).

(c) Percentage distribution of ever married women estimated
in the National Family Health Survey (NFHS)-3 (NFHS, 2009).

(d) The majority of the tribals are engaged in agriculture
and nonformal economic activities such as food gathering and
hunting; rarely they are engaged in formal occupations. For
the tribal population the employment rate should be
considered as the work participation rate (Shankar &
Thamilarasan, 2003).

Table 2 Health Indicators of Tribal and Nontribal Populations in
India

Indicators                                  Tribal    Nontribal
                                                     or national

Neonatal mortality (a)                       41.9       35.2
Infant mortality (a)                         63.7       50.4
Child mortality (a)                          37.9       9.3
Under 5 mortality (a)                       101.6       59.7
Total fertility rate (b)                     3.12      2.68
Not currently using any contraception (b)    60.9%     46.5%
Access to health care
Pregnant mothers who received antenatal      40.2%     50.7%
  care from a health professional
Mothers who received postnatal care from     22.1%     36.4%
  a health professional within 2 days of
  delivery for their last birth
Birth assisted by a health professional      26.9%     48.3%

Source: Indian National Family Health Survey-3 (National Family
Health Survey, 2009).

(a) Number of deaths per 1000 live births.

(b) Rates for women aged 15-49 years.
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