Introduction:
In developing countries maternal and child health is characterized by numerous deprivations like caste, class, gender, spatial distribution and inequality in health outcomes. The inequality in healthcare of mother has strong influence on the health of her child. About one-third equates to total disease burden in women of 15-44 years of age in developing countries. Every minute of every day a woman dies due to pregnancy and child complications [1].
Anaemia is the condition with low number of red blood cell or hemoglobin than the normal. Iron deficiency is thought to be the most common cause of anaemia and inter-connected to other adverse conditions, such as folate, vitamin B12 and vitamin A deficiencies. Anaemia is a prevailing public health concern in developing countries like Africa and Asia particularly among women of reproductive ages who are physiologically more vulnerable to disease. Globally, the prevalence of anaemia is 41.8% among pregnant women and 30.2% among non-pregnant women [2-3].
Antenatal care is dichotomous variable, having or had one or more visits to a trained person during pregnancy. It includes a routine follow-up provided to all pregnant women at primary care level from screening to intensive life support during pregnancy and up to delivery. Antenatal care is highly stressed in order to avoid pregnancy and other related complications and to monitor well-being of mother and fetus until delivery. Postnatal period is defined as six month after childbirth: it is most critical period to the health and survival of mother and new-born [4-5]. Antenatal care (ANC) and Postnatal care (PNC) for mothers and newborns which is improvised healthcare services reduces the vulnerability of women to pregnancy related complications and disease [6].
Estimates of population fertility characteristics are of critical importance for understanding short-term shifts in population age structure and related growth dynamics. A woman’s fertility has direct relation with maternal health care. Fertility indicators such as crude birth rates and reproductive loss are helpful in assessing the health of women which in turn affects population dynamics [7-8].
Immunization is one of the most cost effective interventions that prevent needless suffering through sickness, disability and death. It benefits in improving health and life expectancy [9]. The immunization program will reduce the burden of vaccine preventable diseases and result in achieving the MDG goal to reduce the child mortality.
Khasi- Matrilineal Society
Meghalaya is one of the north-eastern states of India. The term Meghalaya means “abode of Clouds”. The state is situated on hilly terrain having mesmerizing valley, caves, waterfalls and living root bridges. The state is unique in its characteristic for practicing matrilineal system where the lineage is traced through the mother. Women have a privileged status and the youngest daughter is the custodian of the ancestral property. The state is largely inhabited by three tribes namely Khasi and Jaintia (Austro-Asiatic speaking) and Garo (Tibeto-Burman speaking). The present study was conducted at Cherrapunjee (presently Sohrapunjee) is subdivision of East-Khasi hills.
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Figure 1: Map showing the field area |
Methodology
To gain insight about the health of mother and child health in Khasi population an exhaustive fieldwork was conducted between October 2016 and June 2017 in Khleihshnong Sohra. Data was collected using pretested and modified interview schedules. Relevant information on the demographic profile, reproductive performances of mother, healthcare behaviour and nutritional health profile of 399 women in their reproductive ages was collected. Screening of hemoglobin level was also done for 239 women in reproductive ages to detect iron-deficiency by simple prick method using hemoglobinometer. Estimation of anemia status was done by using predefined cut-off points for mild, moderate and severe anaemia following WHO standards for women above age 15 years. For non-pregnant women, any anaemia was defined as Hb<12 g/dl, and for pregnant women as <11 g/dl: this included the categories of mild, moderate and severe anaemia. Mild anaemia was defined as 10–11.9 g/dl for non-pregnant women and 10–10.9 g/dl for pregnant women. Moderate/severe anaemia was defined as Hb<10 g/dl for both [10]. Besides theses, demographic, cultural and behavioral factors like age, birth control measure and health awareness were also considered in the present study. Standard statistical tools were used in data analysis using MS. Excel and SPSS version 18.
Results:
Table 1 depicts the maternal health profile of Khasi women. It is seen that more three-fourth of women have availed the antenatal care facilities during their last pregnancy in which majority of them visited government hospital for their antenatal check-ups. The supplementation coverage was found to be about 80 % and 70% of them received tetanus toxoid injection. Nearly three-fourth of the deliveries was institutional and conducted by trained personnel. The health seeking behaviour with respect to PNC among Khasi women was found to be 65.68%. The anemia prevalence was found to be 90% among non-pregnant and 30.76% in pregnant ever-married women. Awareness for HIV/AIDS is found as nearly 60% but roughly 70% of women were unaware regarding anemia and RTI/STIs which is a matter of concern.
| Table 1: Maternal and child health indicators based on last pregnancy |
Indicators (Currently married women (15-49 years) |
Number (%) |
Antenatal care (ANC) |
Women who receive any antenatal check up |
341(85.46) |
If yes, at least four visits |
149(37.34) |
Government hospital |
250(62.65) |
Private hospital/clinic |
61(15.28) |
Complete Antenatal check-up, |
316(79.19) |
Supplementation |
Women who consume 100 IFA tablets |
308(77.19) |
Vitamin B12 taken |
304(76.19) |
Calcium supplementation |
311(77.94) |
Vitamin A supplementation |
159(39.84) |
Women with at least two tetanus toxoid injection |
283(70.92) |
Delivery care |
Institutional delivery |
298(74.68) |
Delivery at home |
41(10.27) |
Delivery conducted by trained personnel |
308(77.19) |
Delivery type- Normal |
248(62.15) |
Caesarean |
71(17.79) |
Postnatal Care(PNC) |
Women received post natal care(within 6month of delivery) |
245(65.68) |
None |
90(24.12) |
Anaemia prevalence |
85.41 |
Non-pregnant |
90.83 |
Pregnant |
30.76 |
Awareness Status |
HIV/AIDS-Aware |
276(58.89) |
Unaware |
80(20.05) |
Anaemia |
Aware |
74(18.54) |
Unaware |
266(66.66) |
RTI/STD |
Aware |
40(10.02) |
Unaware |
309(77.44) |
The anemic status among Khasi ever married women is given in table 2. It was found that majority of women have mild anemia in all the age categories of non-pregnant women. Moderate anemia is found to be more in higher age cohorts of non-pregnant women and a few with severe anemia in early age groups. This indicates the prevailing adverse health condition among the Khasi women, the probable reason of which may be environment and diet combined with poor health seeking behavior. The different age groups of non-pregnant and pregnant women were compared with respect to different categories of anemia. The difference however, was found to be statistically non-significant in both non-pregnant (P value-0.005<0.7) and pregnant (P value-0.005<0.008).
| Table 2: Prevalence and types of anemia among ever-married Khasi women |
| Women (15-49 years of age) |
Normal |
% |
Anaemic status |
Chi-square |
Mild |
% |
Moderate |
% |
Severe |
% |
Non pregnant(n=262 |
0.7 |
15-19 |
3 |
27.27 |
6 |
54.45 |
2 |
18.18 |
0 |
0 |
20-24 |
7 |
8.13 |
51 |
59.30 |
26 |
30.23 |
2 |
2.32 |
25-29 |
12 |
11.0 |
62 |
56.88 |
30 |
27.52 |
5 |
4.58 |
30-34 |
2 |
5.12 |
23 |
58.97 |
12 |
30.76 |
2 |
5.12 |
35-39 |
1 |
8.33 |
6 |
50.0 |
5 |
41.66 |
0 |
0 |
40-44 |
0 |
0 |
1 |
50.0 |
1 |
50.0 |
0 |
0 |
45-49 |
0 |
0 |
1 |
33.33 |
2 |
66.66 |
0 |
0 |
Pregnant (n=26) |
0.08 |
15-19 |
9 |
100 |
0 |
0 |
0 |
0 |
0 |
0 |
20-24 |
4 |
40.0 |
3 |
30.0 |
3 |
30.0 |
0 |
0 |
25-29 |
4 |
80.0 |
0 |
0 |
1 |
20.0 |
0 |
0 |
30-34 |
0 |
0 |
2 |
100 |
0 |
0 |
0 |
0 |
Logistic regression analysis was done to assess the risk of anaemia among the pregnant and non-pregnant age groups (Table 3). The differences between the pregnant and non-pregnant women in both younger and older age categories with respect to their anemic status are found to be statistically significant (p=0.001). The adjusted odds ratio among younger age group was found to be [OR=0.05 95% C.I (0.001-0.17] and in older age group as [OR=0.007 95% C.I (0.001-0.38] which predicts higher risk of anemia among non-pregnant.
| Table 3: Logistic regression (odds ratio=OR) of different anemia categories and normal women |
| Category |
Status |
Normal |
Mild |
Moderate |
Severe |
Total anaemic |
P-value |
OR
(95% C.I) |
Younger age
(15-24years) |
Non-Pregnant |
10 |
57 |
28 |
2 |
87 |
0.001 |
0.05 (0.01-0.17) |
Pregnant |
13 |
3 |
3 |
0 |
6 |
Older age
(25-34 years) |
Non-Pregnant |
14 |
85 |
42 |
7 |
134 |
0.001 |
0.007 (0.01-0.38) |
Pregnant |
4 |
2 |
1 |
0 |
3 |
Some demographic rate i.e crude birth rate (CBR), infant mortality rate(IMR) and total fertility rate (TFR) of the present population were calculated and compared with those of North-eastern states and India (table 4). CBR (13.5) and IMR (7.5) of the Khasi are found to be lowest although Meghalaya state recorded the highest CBR and IMR among all the north-eastern states and the total Indian figures [3, 7]. TFR in present study is same as Indian average suggesting that this population is going through a demographic transition similar to Indian experiences.
| Table 4: Demographic rates among Khasis with respect to neighboring north-eastern states |
| North-eastern states |
Crude Birth Rate |
Infant Mortality rate |
Total Fertility Rate |
Source |
INDIA |
20.4 |
34 |
2.3 |
SRS 2017 |
Arunachal Pradesh |
18.9 |
36 |
2.7 |
SRS 2017 |
Manipur |
12.9 |
11 |
1.5 |
SRS 2017 |
Meghalaya |
23.7 |
39 |
3.1 |
SRS 2017 |
Mizoram |
15.5 |
27 |
2 |
SRS 2017 |
Nagaland |
14 |
12 |
2 |
SRS 2017 |
Sikkim |
16.6 |
16 |
2.1 |
SRS 2017 |
Tripura |
13.7 |
24 |
1.7 |
SRS 2017 |
Present study |
13.5 |
7.5 |
2.3 |
SRS 2017 |
Table 5 describes the relationship demographic variables with respect to healthcare seeking before, during and after childbirth. The data was analyzed across age-cohort for ANC, delivery care, PNC, contraceptive use and HIV/AIDS awareness. The data suggests that maternal age has no significant impact on maternal health seeking care (P-value ANC>0.005; Delivery care > 0.005; PNC>0.005). Contrary to this relationship between BCM and ANC is found to be statistically significant (P value-0.001) which is indicative of consciousness of Khasi women in availing modern health amenities.
| Table 5: Maternal health care among the Khasi |
| Variable |
Antenatal care |
Delivery care |
Postnatal care |
Complete |
Partial |
p-value |
Institutional |
Non-institutional |
p-value |
Yes |
None |
p-value |
Maternal age(N) |
|
|
0.41 |
|
|
0.5 |
|
|
0.7 |
15-19 (21) |
3 |
8 |
9 |
2 |
6 |
6 |
20-24(135) |
45 |
62 |
101 |
10 |
87 |
45 |
25-29(134) |
68 |
59 |
115 |
14 |
95 |
32 |
30-34(48) |
19 |
32 |
42 |
10 |
34 |
16 |
35-39(20) |
10 |
7 |
14 |
5 |
12 |
7 |
40-44(5) |
3 |
2 |
5 |
0 |
3 |
1 |
45-49(5) |
2 |
2 |
3 |
1 |
3 |
1 |
BCM(326) |
|
|
0.001* |
|
|
0.2 |
|
|
0.40 |
User |
165 |
137 |
276 |
34 |
224 |
83 |
Non-user(11) |
5 |
5 |
8 |
3 |
9 |
1 |
Awareness |
|
|
0.04* |
|
|
0.0** |
|
|
0.0** |
HIV/AIDS(357)
Aware
Unaware(80) |
125
20 |
138
42 |
246
49 |
21
21 |
204
37 |
61
29 |
| *Based on last live birth |
The perception of child healthcare with respect to breastfeeding and child immunization is given in table 6. Both were selected as defining variable in order to understand the status of child health. The impact of maternal age on these variables was found as statistically non-significant. However, more than half of total cases breastfed babies across different age groups fall short of the medically prescribed norm for exclusive breastfeeding. A small proportion of children (1%) have not received the full immunization as prescribed by Meghalaya health department, but on the whole child immunization appears to be the prime concern in their childcare and overall health seeking behaviour of the Khasis. The vaccine acceptance was found to be more among early age women than the older ones. A contrary trend was recorded in study controlling for confounding factors in Mali and Burkina, Faso found that children born to urban teenagers were significantly less likely to be vaccinated than children born to mothers aged 25–29[11]
| Table 6: Breast feeding and child immunization practice among Khasi |
| Variable |
Child health |
|
Breastfeeding |
Chi-square |
Immunization |
Chi-square |
Maternal age(N) |
Less than 6 months |
6 months and above |
Complete |
partial |
15-19(21) |
5 |
5 |
0.7 |
11 |
0 |
0.2 |
20-24(135) |
57 |
47 |
102 |
1 |
25-29(134) |
60 |
63 |
120 |
1 |
30-34(48) |
21 |
26 |
47 |
1 |
35-39(20) |
10 |
8 |
17 |
1 |
40-44(5) |
2 |
3 |
5 |
0 |
45-49(5) |
0 |
4 |
4 |
0 |
| *Based on last live birth |
Discussion and Conclusion
The maternal health indicators discussed above are found to have direct influence on the health of mother and child among the Khasis. In expecting mothers anemia is one if the causes of morbidity. In present study the anemia was found to be high among non-pregnant ever-married women than the pregnant ones which is detrimental to future population health. The total fertility rate (2.3) which is similar to the national average is indicative of the Khasi having high growth rate as India. But since the maternal age across different cohorts have no significant influence on utilization of healthcare before during and after pregnancy it is probable that cultural barriers have its spheres of influence on the health seeking behavior of the Khasis. A similar non-significant influence is also observed in breast feeding practices where maternal age has no impact irrespective of expected changes in the trends of education and awareness level. Adherence to traditional belief systems can become an obstacle to appreciate modern medical knowledge.
On the other hand birth control measures and awareness level has significant impact on the outcome of overall health. The study incisively highlights that the fertility outcome in a matrilineal society which is a reflection of a complex reality which is characterized by the dynamics of a conventional and straight forward demographic process. Formulation of appropriate population policies with emphasis on the cultural dimension is required to address the maternal and child health needs of the region. It is necessary to explore the influence of culture and belief systems on the overall health related issues of the Khasis and the northeast India in general.
Ethical clearance
The study has been approved by Ethical clearance Committee held at Department of Anthropology, University of Delhi.
Conflict of Interest
The authors have declared there is no conflict of interest.
Abbreviations
ANC- Antenatal care
PNC-Postnatal care
CBR-Crude Birth Rate
IMR-Infant Mortality rate
TFR-Total Fertility Rate
Hb- Hemoglobin
HIV/AIDS- Human Immunodeficiency Virus Infection/Acquired Immune Deficiency Syndrome
RTI/STIs-Reproductive Tract Infection/Sexually Transmitted infections
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