Introduction:
Reproductive health is allied with the reproductive system of women and its functions and processes. [1] It plays a vital role to deliver a healthy child and that implies a woman should have a well-maintained reproductive span, capable of having a responsible, self-sufficient lifestyle, ability to reproduce and freedom to make any decision, when and how often, to do so. [1] A woman could access secure, efficient, affordable and acceptable techniques of fertility regulation, choice, and should have the provision of access to the appropriate healthcare services, which enable to go safely through pregnancy and childbirth processes with the finest chance of having healthy children. [1,2] The high importance of reproductive health in human societies has been globally recognized under reproductive rights, as women's health directly affects the long-term programs of developments. [3,4] Women's reproductive health status is connected with a number of interrelated biological, socio-cultural and lifestyle factors. [5-8] Women reproductive health is considered to be a very essential element for a healthy child who is free from any infectious diseases and deformities. [9-12] Therefore, one should have complete knowledge about consequences of early pregnancy, infertility, birth control methods, preterm-pregnancy, during pregnancy, childbirth and post-term care of the infant and mother. [9-12]
Globally, the prevalence of maternal mortality rate was found to be more than half million annually. [2,13] Most women lose their lives due to inadequate knowledge and unhygienic process of reproduction (e.g., postpartum mortality) and sadly, out of those deaths 99.0% accounted in developing countries. [2,13] Moreover, initially the future generations of a nation depend on the reproductive system of the population, especially women. A major essence of the diseases abnormalities and adverse health outcome are mostly dependent to their reproductive system and functions, the manner society ignores and poor awareness about women's health status (both physical/mental). [5,7,8,11] Several research studies have reported that there has been an enormous expansion in healthcare services, strategies, schemes and technologies that provided facility related to reproductive health in women, but it doesn't work up to the optimal level. [7,8,11,14]
Further, the reproductive health status is getting better than the previous decades but not up to the satisfying point. [15] It was also reported that the (e.g., rural women) age of the mother, birth intervals between two children, gender inequality, non-use of contraceptives, lack of knowledge and awareness about reproductive health and unable to access the maternal healthcare services are the prime barrier towards the success of Millennium Development Goals. [15,16] India is a developing country and its ethnic/tribal populations constitute about 8.61% of the total population, and Assam constitutes 12.45% of ethnic/tribal population. The reproductive health status of the tribal populations in India was miserably poor compared to the rest of the society. [9-11] The literature search showed that there is an immense paucity of research among these tribal/ethnic populations of India, particularly the most vulnerable segment is the North-east Indian population. Due to lack of focus, their social, economic and health status is still in critical and unprivileged condition. Several initiatives have been taken by the government since independence in order to uplift the deprived conditions of tribal communities with a view to eliminate the social exclusion and to assimilate them into the mainstream society, [9,12,17,18] but those development projects caused crucial failure and are not able to achieve the desired success so far in target populations. [9,12,17,18] Therefore, the present investigation was undertaken with the objective to evaluate the associations of early age at marriage, early childbearing, use of contraceptive methods and reproductive health consequences among Mishing tribal women of Assam, Northeast India.
Materials and Methods
The present community based cross-sectional investigation was carried out among indigenous Mishing tribal women of Khaboli Ghat and Pohumara areas of North Lakhimpur Block of Lakhimpur District, Assam (26°48’N and 27°53’N, 93°42’E and 94°20’E). The district has a population density of 458 individuals/ km2 with a total population of 1042137 individuals (males: 529674; females 512463) and literacy rate 77.20% (males: 83.52%; females: 70.67%). This district has inhabitants of both caste people including Chutia, Ahom, Koch, Kalita, Kaiborta and the ethnic/tribal populations of Mishing, Deuri, Hajong, Sonowal Kachari, Boro Kachari and Khamti populations. The present study was undertaken among the indigenous Mishing population, the second largest ethnic/tribal group in Assam. They are generally considered to be an endogamous tribal population belonging to the Indo-Mongoloid ethnicity and the Tibeto-Burman linguistic family, who shows close physical and socio-cultural affinity with the Adis of Arunachal Pradesh. [19] This study was undertaken among the married women of reproductive ages (15-49 years) residing in rural areas, and homogeneous in nature mainly consisting of Mishing tribal population. The research participants were included utilizing the household visits and stratified random sampling method. Research participants with disease and physical deformity were excluded to avoid the subject selection ambiguity. The minimum number of participants required for reliably assessment of the reproductive health-related outcomes was determined using the following standard sample size estimation method. [20] In this method, the anticipated population proportion of 50%, absolute precision of 5% and confidence interval of 99% are taken into consideration. The minimum sample size estimated was 664 individuals. A total 1140 research participants were approached, out of which 1056 research participants voluntarily participated in the present investigation. The overall participation rate was 92.63%. The detailed objectives, nature of participation and procedures of data collection were explained and informed consents were obtained before collection of data. The study was conducted in accordance with the ethical guidelines and standard methods for human experiments as laid down in the Helsinki Declaration. [21]
Collection of Reproductive health related data
A pre-structured and face-to-face interview was conducted among tribal women of the households to collect relevant information related to reproductive health status. Special care was taken in order to get the correct response from the respondents. Information includes the use and non-use of family planning methods and type of the family planning method, attitude towards the family planning and contraceptive, birth interval of the children, age at marriage and age a first child, total number of conceptions, total number of live birth or still birth if any, miscarriage, abortion (e.g., induced or spontaneous) and various problem related to the reproductive system and health etc.
Statistical Analysis
The data entry was done on MS Excel and statistical analysis was carried out using the Statistical Package for Social Sciences (SPSS; version 16.0) and MS Excel. Poisson distribution with 95% confidence interval (CI) is calculated for the average number of cases in different categorical variables for the time in the present study. Chi-square analysis (Χ2) was done to assess the age-differences in adverse reproductive outcome variables. Binary logistic regression (BLR) analysis was done to find out the associations of reproductive health related variables and socio-economic variables with adverse reproductive outcomes (e.g., miscarriage, abortion and stillbirth). The BLR model allows for controlling the determinant variables by comparing with a reference category. The dependent variables were formed in regression model by those research participants have reported to be miscarriage, abortion and stillbirth, separately. BLR analysis was performed for the determinant variables (e.g., age at marriage, age at first child, number of conceptions, family planning method, types of family planning, reproductive complications, education, occupation and family income) that could be associated with the adverse reproductive outcomes. The predictor variables were given into the BLR model analysis as a set of variables, and outcomes were determined by comparing with the reference group. A p-value of <0.05 was considered to be statistically significant.
Results
The frequency distribution of reproductive history and socio-economic variables among Mishing tribal women is shown in Table 1. Results showed that 23.30% (95% CI: 216.2-278.7) women get married at an early age (e.g., <15 years), whereas more than half of the women 52.90% (95% CI: 513.6-607.3) at 16-20 years. Further, early pregnancy (<18 years) was observed among 39.50% (95% CI: 377.9-459.1) and 93.65% (95% CI: 929.3-1052.6) women found to have 1-5 children. Women using family planning methods (29.70%) were found to be significantly lower than the non-users (70.30%), amongst the users mostly preferred oral contraceptives (20.20%) (95% CI:154.4-243.6) (Table 1). Further, the overall prevalence of miscarriages and stillbirths were observed to be 54.45% (95% CI: 529.0-623.9) and 5.0% (95% CI: 47.5-79.5) due to various health problems. A majority of the tribal women
(80.02%; 95%CI: 789.9-903.3) have reported various reproductive complications and 12.0% (95% CI: 107.7-153.3) reported the induced abortion of the fetus using both modern medical and traditional methods (Table 1).
| Table 1: Reproductive history and socio-economic variables among Mishing tribal women of Assam, India |
| Reproductive History |
N (95% CI) |
(%) |
Age at marriage |
<15 years |
246 (216.2-278.7) |
23.30 |
16-20 years |
559 (513.6-607.3) |
52.90 |
≥21 years |
251 (162.1-216.9) |
23.80 |
Age at first child |
≤18 years |
417 (377.9-459.1) |
39.50 |
19-25 years |
547 (502.1-594.9) |
51.80 |
≥26 years |
92 (74.16-112.83) |
8.71 |
Number of Conception |
1-5 Children |
989 (929.3-1052.6) |
93.65 |
≥6 Children |
67 (51.9-85.1) |
6.34 |
Family Planning |
Yes |
314 (280.2-350.8) |
29.7 |
No |
742 (690.5-797.3) |
70.3 |
Types of Family Planning methods |
Copper-T |
31 (21.1-44.0) |
2.90 |
Oral Pill |
213 (185.4-243.6) |
20.20 |
Other (e.g; Condom) |
70 (55.57-88.44) |
6.6 |
Abortion (Induced) |
Yes |
129 (107.7-153.3) |
12.25 |
No |
927 (869.2-988.6) |
87.80 |
Miscarriage |
Yes |
575 (529.0-623.9) |
54.45 |
No |
481 (438.9-525.9) |
45.50 |
Still Birth |
Yes |
62 (47.5-79.5) |
5.87 |
No |
994 (934.1-1057.7) |
94.10 |
Reproductive complications |
Yes |
845 (789.9-903.9) |
80.02 |
No |
211 (183.5-241.5) |
19.98 |
Education |
<8th standard |
436 (396.05-478.90) |
41.3 |
≥8th standard |
620 (573.08-670.76) |
58.7 |
Occupation |
Housewife |
1048 (986.44-1113.40) |
99.2 |
Working/Services |
8 (3.45-15.76) |
0.8 |
Family Income |
<Rs. 10000 |
985 (925.38-1048.46) |
93.3 |
≥Rs. Rs. 10000 |
71 (55.45-89.56) |
6.7 |
Age-related effect on adverse reproductive consequences and multiple conceptions among Mishing tribal women
The age-specific frequency distribution (95%CI) of adverse reproductive consequences (e.g., induced abortion, miscarriage and stillbirth) and number of conceptions among Mishing tribal women are depicted in Table 2. The age-specific induced abortion (37.98%) was observed to be higher among 20-24 years. The prevalence of miscarriage (50.08%) and stillbirths (27.41%) were observed to be higher among 25-29 years. The age-specific higher conception of the 1-5 children (38.11%) and ≥6 children (40.29%) were observed to be higher among 25-29 years. The magnitude of induced abortion (3.10%), miscarriage (3.30%) and stillbirth (3.22%) was observed to be lower among 15-19 years. Using chi-square
analysis, the age-specific difference in prevalence of miscarriage (Χ2=26.61; p<0.05) and conception of children (≥6 number) (Χ2=58.66; p<0.05) were found to be statistically significant, but age-specific differences were not significant in abortion (Χ2=8.33; p>0.05), stillbirth (Χ2=5.24; p>0.05) and conception of children (1-5 number) (Χ2=0.99; p<0.05) (Table 2).
| Table 2: Age wise distribution of Women with Abortion (induced). Miscarriage, Still birth and total Number of Conception of Children among Mishing women |
| Age groups (N) |
Abortion
N (95% CI) |
(%) |
Miscarriage
N (95% CI) |
(%) |
Still Birth
N (95% CI) |
(%) |
Number of Conception |
1-5 children
N (95% CI) |
(%) |
≥6 children
N (95% CI) |
(%) |
15-19 years
(N=52) |
4
(1.09-10.94) |
3.10 |
19 (11.44-29.67) |
3.30 |
2
(0.24-7.22) |
3.22 |
52
(38.84 - 68.19) |
5.25 |
0
(0.00-3.69) |
0.00 |
20-24 years
(N=305) |
49
(36.25-64.78) |
37.98 |
125 (104.5-148.93) |
21.73 |
17
(9.9.-27.22) |
27.41 |
303 (269.84-339.09) |
30.63 |
2
(0.24-7.22) |
2.98 |
25-29 years
(N=404) |
43
(31.12-57.92) |
33.33 |
288
(255.70-323.2) |
50.08 |
21
(13.00-32.10) |
33.87 |
377
(339.92-471.05) |
38.11 |
27 (17.79-39.28) |
40.29 |
30-34 years
(N=190) |
20 (12.22-30.89) |
15.50 |
86
(68.79-106.21) |
14.95 |
13
(6.29-22.23) |
20.96 |
167 (142.64-189.86) |
16.88 |
23
(14.58-34.51) |
34.32 |
35-39 years
(N=84) |
13
(6.92-22.23) |
10.07 |
42
(30.27-56.77) |
7.30 |
9
(4.12-17.08) |
14.51 |
78
(61.66-97.35) |
8.68 |
6 (2.20-13.06) |
8.95 |
40-45 years
(N=21) |
0
(0.00-3.69) |
0.00 |
15
(6.40-24.74) |
2.60 |
0
(0.00-3.69) |
0.00 |
19
(11.44-29.67) |
1.92 |
9 (4.12-17.08) |
13.43 |
15-45 years
(N=1056) |
129 (107.70-153.2) |
12.25 |
575
(529.02-623.9) |
54.45 |
62
(47.54-79.48) |
5.87 |
989
(929.24-1073.3) |
93.65 |
67
(51.92-85.09) |
6.34 |
Chi-value |
8.33* |
26.61** |
5.24* |
0.99* |
58.66** |
Associations of Reproductive health related issues and socio-economic variables with reproductive outcomes among Mishing tribal women
The BLR model was fitted to find out the odds for reproductive complications as miscarriage, abortion and stillbirth with reproductive history and socio-economic variables are shown in Table 3. The results showed that early marriage <15 years (Odds: 1.78; 95%CI: 1.02-2.87) and 16-20 years (Odds: 1.85; 95%CI: 1.26-2.70) found to have significant effects on miscarriage (p<0.05). However, early pregnancy (i.e., ≤18 years; Odds: 44.62; 95%CI: 5.07-392.18) and 19-25 years (Odds: 5.87; 95%CI: 1.57-21.86) have significantly higher risks of stillbirths (p<0.01). The women were not using any family planning method found significantly higher risks of miscarriage (Odds: 5.76; 95%CI: 3.22-10.31) and induced abortion (Odds: 3.49; 95%CI: 1.41-8.57) (p<0.01). The results showed that tribal women used oral contraceptive found to have significant higher risk of adverse reproductive complications of miscarriage (Odds: 11.76; 95%CI:6.40-21.59), abortion (Odds: 11.42; 95%CI:4.84-26.91) and stillbirth (Odds: 24.36; 95%CI:5.47-108.34) (p<0.01). Similarly, women experience various reproductive complaints have significantly increased the higher risks of miscarriage (Odds: 2.87; 95%CI: 1.63-5.04) and stillbirths (Odds: 20.93; 95%CI: 5.69-76.97) (p<0.01). Socio-economic determinants of women's education (i.e., <8th standard; Odds: 0.46; 95%CI: 0.28-0.74) and monthly family income (i.e., Rs. <10000; Odds: 4.44; 95%CI: 1.12-17.45) found to be significantly associated with induced abortion among Mishing tribal women (p<0.05).
| Table 3: Reproductive history and socio-economic variables among Mishing tribal women of Assam, India |
Variables |
Miscarriage [N=575] |
Abortion [N=129] |
Stillbirth [N=62] |
Odds
(95% CI) |
Wald |
Odds
(95% CI) |
Wald |
Odds
(95% CI) |
Wald |
Age at marriage |
<15 years |
1.78* (1.02-2.87) |
4.21 |
2.53 (0.98-6.50) |
3.70 |
0.61 (0.15-2.39) |
0.50 |
16-20 years |
1.85* (1.26-2.70) |
9.92 |
1.71
(0.75-3.88) |
1.64 |
0.38
(0.13-1.00) |
3.77 |
≥21 years® |
1 |
Age at first child |
≤18 years |
1.42 (0.61-3.23) |
0.68 |
3.03
(000) |
0.000 |
44.62* (5.07-392.18) |
11.73 |
19-25 years |
1.45
(0.71-2.95) |
1.04 |
1.95 (0.80-4.69) |
2.20 |
5.87*
(1.57-21.86) |
6.96 |
≥26 years® |
1 |
No of Conception |
1-5 Children |
0.79
(0.34-1.83) |
0.28 |
2.53 (0.53-11.93) |
1.38 |
0.005
(0.00) |
0.00 |
≥6 Children® |
1 |
Family Planning |
No |
5.76**
(3.22-10.31) |
34.77 |
3.49**
(1.41-8.57) |
7.39 |
1.09
(0.19-5.90) |
0.01 |
Yes® |
1 |
Types of Family Planning |
Oral Pill |
11.76**
(6.40-21.59) |
63.21 |
11.42**
(4.84-26.91) |
30.97 |
24.36**
(5.47-108.34) |
17.59 |
Other Methods (e.g. Condom,Copper-T)® |
1 |
Reproductive complications |
Yes |
2.87**
(1.63-5.04) |
13.42 |
1.29
(0.000) |
0.000 |
20.93**
(5.69-76.97) |
20.94 |
No® |
1 |
Education |
<8th standard |
1.16
(0.89-1.51) |
1.22 |
0.46*
(0.28-0.74) |
10.17 |
0.77
(0.40-1.46) |
0.64 |
≥8th standard® |
1 |
Occupation |
Housewife |
0.56
(0.11-2.81) |
0.49 |
0.28
(0.01-5.01) |
0.74 |
6.47
(0.000) |
0.00 |
Working/Services ® |
1 |
Family Income (in rupees) |
<Rs. 10000 |
1.16
(0.89-1.51) |
0.56 |
4.44*
(1.12-17.45) |
4.55 |
1.58
(0.31-8.00) |
0.30 |
≥Rs.10000® |
1 |
| ®Reference category; *p<0.05, **p<0.01 |
Discussion
Reproductive women experience higher mortality risk factors due to high pregnancy and unawareness toward utilization of healthcare facilities in India, which was found to be 50 times higher than women in developed countries. From the past several researchers affirmed that at least 50% of women of all age groups are suffering from nutritional deficiencies (e.g., anaemia), undernutrition (e.g., thin or underweight) and reproductive health related complications. [15,22,23] The present intervention programs for up-building of the reproductive health status of women are including family welfare, child survival, maternal and child health, safe motherhood initiative, and postpartum programs that were not able to achieve desired goals.
The present investigation revealed that Mishing tribal women get married (<15 years; 23.30%) and start conceiving at a very young age (≤18 years; 39.50%) (Table 1), and a very significant segments conceive with a higher number of children (33.81%) and also witness significant adverse reproductive complications by the age of 24 years (Table 2). Banerjee et al. [24] reported a similar situation in rural women in Jharkhand, India, where the reproductive histories of young women clearly reflect the continuing trends of early pregnancy and high fertility.
Further, International Planned Parenthood Federation and Guttmacher Institute report [25] reported that 31% of Indian women were getting married at an early age of 15-19 years. However, the decadal trend has shown significant decline in early age at marriage (i.e., 15-19 years) during 1991-2011 in India. Mavelil and Srivastava [10] have reported early marriage in Meghalaya North-East India (81.7%) of women getting married between 13-18 years of age. Results of the present investigation showed that 76.10% of the Mishing tribal women get married at ≤20 years (Table 1). A large-scale population survey report showed that 37% of women get married at an early age (≤18 years) and 47% at age 20-24 years despite multiple intervention policies in India. [26] Several studies have also reported the occurrence of early age marriages, early childbearing and adolescent pregnancies among Indian tribal and non-tribal women. [6,9,12,18, 24, 27, 28]
Results of BLR analysis showed that age at marriage of <15 years (1.78 times) and 16-20 years (1.85 times) had significantly higher risks of miscarriage among Mishing tribal women (Table 3). Moreover, the results indicated that the multiple national policies against early marriage and promotion of awareness programmes by the government were not reaching the deep rural tribal populations. The BLR analysis showed that early age at conception (i.e., ≤18 years) had significantly increased (Odds: 44.62 times) the risks of stillbirths among Mishing tribal women (p<0.01) (Table 3).
Researchers have confirmed severe adverse reproductive health consequences, miscarriages, stillbirths, physical growth retardation, anemia, nutritional thinness or chronic energy deficiencies and poor reproductive outcomes due to early age at marriages among Indian women. [6,12,18,23,27,28] Present investigation has reported that >90% of Mishing tribal women have 1-6 number of surviving children, and more than 50% of Mishing women had experienced at least one adverse pregnancy outcome (e.g., miscarriage or abortion and still birth) during the reproductive periods (Table 2). The large numbers of children may be attributed to early marriage, early and longer fertility period, inadequate access or utilization of family planning methods or fertility control, inadequate birth spacing and mortality among Mishing tribal women. Present investigation demonstrated very higher magnitude of adverse reproductive consequences compared to reproductive women in Assam (abortion: 5.5%, miscarriage: 4.4%, and stillbirth: 0.5%).[29]
Recent data showed that 66 abortions took place per 1,000 women in 2015, and majority were (74%) performed without any medical facility or supervision. [30] The numbers of induced abortion are very high (12.25%) as they are unaware of the modern and institutionalized healthcare services and legalization of abortion (Table 2). Similar studies have reported lower prevalence of abortion among the rural young in Jharkhand (3.0%), [24] but the prevalence was observed to be significantly higher in Indian youth (41.0%).
Present investigation showed that the family planning methods of the Mishing tribal women were far from the family planning methods launched by Indian government, women rarely accept modern methods, including condoms, oral contraceptive pills or intrauterine contraceptive devices (e.g., copper T); only 29.7% of women were found to be using various family planning methods (Table 1). The BLR analysis showed that risks of induced abortion (Odds: 5.76 times) and stillbirths (Odds: 3.49 times) were found significantly higher among Mishing tribal women who had not adopted any family planning methods (p<0.01) (Table 3). Hence, the result indicates significantly lower use of effective contraceptives and poor awareness of family planning methods among Mishing tribal women. Beyond that, even if they were not satisfied with the contraceptives, sometimes women begin complaining about malfunction or partial/side effects of the available modern family planning methods.
One study reported that a very small number of rural women use a contraceptive method compared to urban women in Indian. [31] Sivapriya et al. [32] reported that 55.2% urban women were using contraceptives in Chennai (condom 37.2%, copper T 6.9%, traditional methods 5.5% and 2.1% sterilization). Takkar et al. [33] also reported (81.1%) educated working women using contraception (condoms 57.8%, Copper T 24.7%) in Chandigarh. Further, the BLR analysis showed that women who adopted oral contraceptives had reported significantly higher associations of adverse reproductive outcomes (e.g., miscarriage, induced abortion and stillbirths) than other methods (e.g., condom and copper T) (p<0.01) (Table 3).
Narzary and Ao [17] have also reported that oral contraceptive use found to have
significantly higher adverse health effects and morbidity among women in
North-East India. Bhardwaj and Tungdim [9] have reported that use of contraceptives were significantly lower among scheduled tribal women in Rajasthan. Similar study has also reported that use of contraceptives (9% female sterilization, 2% condoms and 2% pills) was found to be low among young married rural women in Jharkhand. [24]
The reproductive health of the Mishing tribal women is very crucial and 80.02% of the research participants had reported various reproductive health related complications including heavy menstrual bleeding, irregularity, abdominal pain during cycle, and menopause in early age, white discharge and reproductive organ related complications. Similar observations were reported among reproductive women in Chennai [32], Delhi [34] and North-East India. [17] Further, results of the present investigation revealed that high prevalence of self-reported miscarriage and induced abortions rate were found to be very high among Mishing women of Assam,
North-East India. (Table 2).
Furthermore, BLR analysis showed that reproductive complications were found to have 2.87 times and 20.93 times (p<0.01) increased risks of miscarriages and stillbirths among Mishing tribal women, respectively (Table 3). Several studies have reported that early marriage has negative impact and substantially increases the risk of adverse pregnancy outcomes (e.g., stillbirths and miscarriages), postnatal complications, poor nutritional status or undernutrition and mortality in women. [6,28,35-38] Researchers have reported an inverted U-shaped effect of age on adverse pregnancy outcomes (e.g., abortion or mortality). [6,37] Present study also revealed the significant association of age on miscarriage and higher number of conceptions among Mishing tribal women (p<0.01). Further, the BLR analysis showed that maternal education (Odds: 0.46 times) and family income (Odds: 4.44 times) were found to have significant associations with induced abortion among Mishing tribal women (p<0.05) (Table 3).
Moreover, the inadequate utilization of healthcare services, poverty, education, socio-economic and demographic conditions, early maternal age, gender discrimination, exposure to various disease complications and poor awareness are also blamed for adverse reproductive health outcomes in Indian women. [6,36,38] The uses of contraceptive methods have also significantly reduced the risk of short birth intervals, high fertility and adverse reproductive outcomes and effect on maternal and child survival. [39,40]
Conclusion
Reproductive health status of the Mishing tribal women is very critical, and early marriage and early conceiving leads to various types of adverse reproductive complications (miscarriage, menstrual problem, physical weakness and reproductive health related issues). Thus, speedy initiatives are urgently needed for the rural tribal population to provide a better education, awareness and understanding toward these concerns. The results indicate the critical need of family planning methods tailored to the high fertility, multiple pregnancies and adverse reproductive outcomes among Mishing tribal women. The findings of the present research investigation should be carefully considered by the service providers in order to increase the mass awareness to understand the potential risk associated with adverse reproductive outcomes, behavior and delivery of healthcare services. Moreover, the emphasis also has to be shifted from curative measures to preventive measures by additional effective and target oriented primary healthcare and awareness programmes should be implemented to uplift the Mishing rural women.
Acknowledgements
Authors gratefully acknowledged the help and cooperation of village level authorities and research participants during the fieldwork. Authors also gratefully acknowledge the extensive help and co-operation of the Department of Anthropology, Assam University, Silchar (Diphu Campus).
Conflict of Interest
The authors have no conflicts of interests regarding the publication of the manuscript.
Financial Assistance
The financial support of the Indian Council of Social Science Research (ICSSR), New Delhi in the form of Short-Term Doctoral fellowship is also acknowledged [Ref. No: RFD/2018-19/GEN/Short-Term/08].
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