Introduction:
Fertility can be defined as the number of children that women produce and mortality is the number of deaths in a given time or place or the proportion of deaths in population. [1-3] Population-specific fertility and mortality are considered to be important measures because their rates help in calculation of growth and reduction over time and space. [4-6] Several socio-economic, socio-cultural, demographic and biological factors have significant impact on fertility and mortality. [6-11] Fertility rates reflect socio-economic developments and most of the developed countries tend to have the lowest birth and total fertility rate in population. [6,12] Poor maternal health status has increased the risk of undernutrition which has proven to be fatal with an increasing number of child-birth, thus increasing the mortality. [3,11,13-17]
The prevalence of child undernutrition and maternal and infant mortality was observed to be higher among rural Indian populations. [3,13,17] Education is considered to be a powerful tool that helps in constructing a society of equality, autonomy, freedom, awareness, justice and decision-making abilities and weapons to overcome the age-old social stigmas that have failed to recognize the women's role in society. [18-21] Several studies have reported significant associations between education, socio-economic and demographic variables with maternal health, nutrition and hygiene of their child health and reproductive outcomes [3,11,15,17,21], which has led to decrease the infant mortality rate and maternity complications. [3,22,23] Moreover, biological factors have significantly contributed equally to determining the population-specific fertility, mortality and health outcomes. [3,6,11,17,24]
Several studies have reported that birth intervals, birth order, mother’s age at birth and labour force participation have strong effects on fetal wastage, infant and child mortality, survival rate, economic burden and mental health status. [3,6,11,15,17,25] Age at marriage is considered to be an important determinant of fertility which directly influences the reproductive periods, higher conceptions, adverse reproductive outcomes, maternal and child mortality and health status. [3,6,11,15,17,25,26] Family planning and use of contraceptives, educational attainment and socio-economic conditions have significant effects to reduce the relative risks of maternal and infant mortality because it reduces unwanted pregnancies and increased birth intervals, thus influencing the fertility and mortality rate in the population. [3,5,6,27] Several studies have reported significantly higher rates of fertility and mortality differences in rural areas than urban populations. [6,28]
India is home of largely
heterogeneous tribal populations constitute 8.61% of the total
population in India, particularly the most vulnerable segment of the
populations attributed to have inadequate focus on their
socio-economic conditions, health status, inadequate and culturally
appropriate healthcare facilities and regional differences mostly
residing rural and remote areas are still found to be unsatisfactory
and underprivileged. Several developmental policies and intervention
programmes are implemented in order to uplift their deprived
socio-economic conditions but are still unable to achieve the
desired success in the target populations. Therefore, the objectives
of the present study are to find the associations of socio-economic
factors affecting the fertility and mortality among the Lepcha
tribal population of North Sikkim, India.
Materials and Methods
Present cross-sectional study was carried out among 110 married Lepcha
tribal women aged between 18-60 years of Dzongu villages of North Sikkim district
of Sikkim, situated at a distance of approximately 74 kilometers from the capital town Gangtok. There are almost 30 villages in the entire Dzongu area and the population consists of the mainly homogenous Lepcha tribal population. Lepchas are mainly living in the northeastern Himalayan region mainly Sikkim and the Darjeeling hills (India), Nepal and south western Bhutan.[29] The influence of Buddhism has grown since the eighteenth century, and in recent times, Lepcha individuals have been seen to be inclined towards Christianity also though often the original shamanistic beliefs and practices are seen to be mixed with those of the new religion.[30] The research participants are homogeneous and endogenous in nature and residing in rural areas and
also incorporated utilizing simple random sampling methods. Further, the objectives of the present study, participation and procedures of data collection were explained and an informed consent was obtained before collection of data. The nature of participation was voluntary in nature and present study was carried out in accordance with the standard guidelines and methods for human experiments as laid down in the Helsinki Declaration. [31]
Socio-economic and demographic data collection
The socio-economic and demographic data was collected by utilizing a semi-structured interview and household survey methods scheduled from June to July of 2019. The fertility and mortality information such as number of conceptions, number of live births, age, sex, marital status, number of dead children, reproductive wastage (e.g., abortion, still births and miscarriage) was collected from married women and their spouses. Data on socio-economic conditions including occupation, household income, education of the informant and their partners, religion, age at marriage, awareness and adoption of the family planning methods were also collected. The income groups of the informants were categorized into low income, middle- and high-income groups and education level were also categorized into primary, secondary and above, and illiterate or who have not attained any formal education.
Statistical Analysis
Data of the present study was statistically analyzed using Statistical Package for Social Sciences (SPSS version 16.0). The quantitative variables are depicted in terms of mean and standard deviations (±SD). Poisson distribution with 95% confidence interval (CI) is calculated for the average number of cases in different categorical variables. The t-test
and one-way analysis of variance (ANOVA) were done to find out the mean differences between the categories and chi-square analysis was done to determine the association in categorical variables. A p-value of less than 0.05 is considered to be statistically significant.
Results
Socio-economic and demographic background of the Lepcha
tribal women of Dzongu, North Sikkim is depicted in Table 1. The results showed that the majority of the women belonged to nuclear families (79.1%, 95%CI: 69.7-107.3), owned pucca houses (57.3%; 95%CI: 48.4-80.6), and lower income group (58.2%, 95%CI: 49.3-81.7). Similarly, the distribution was observed to be higher in the categories of Secondary and above education (57.3%; 95%CI: 48.4-80.6), ‘Yes’ Television (78.2%; 95%CI: 68.8-106.2), Farmer/Housewife occupation (73.6%; 95%CI: 64.3-100.7) and child conception groups (93.6%; 95%CI: 82.2-122.7).
| Table 1: Socio -demographic background of the Lepcha tribal women in Dzongu, North Sikkim |
Socio demographic background |
Frequency
(N= 110) |
95% CI of Frequency |
Percentages (%) |
Marital status |
Married |
107 |
87.7-129.3 |
97.3 |
Divorced and Widow |
3 |
0.6-88 |
2.7 |
Family type |
Joint/ extended |
23 |
14.6-34.5 |
20.9 |
Nuclear |
87 |
69.7-107.3 |
79.1 |
House type |
Kutcha |
12 |
6.2-21.0 |
10.9 |
Pucca |
63 |
48.4-80.6 |
57.3 |
Semi- pucca |
35 |
24.4-48.7 |
31.8 |
Television |
Yes |
86 |
68.8-106.2 |
78.2 |
No |
24 |
15.4-35.7 |
21.8 |
Education |
Primary |
29 |
19.4-41.6 |
26.4 |
Secondary + |
59 |
44.9-76.1 |
53.6 |
Illiterate |
22 |
13.8-33.3 |
20.0 |
Income groups |
Low |
64 |
49.3-81.7 |
58.2 |
Middle |
37 |
26.0-51.0 |
33.6 |
High |
9 |
4.1-17.08 |
8.2 |
Occupation |
Government |
21 |
13.00-3.1 |
19.1 |
Private/ Business |
8 |
3.4-15.8 |
7.3 |
Farmer/ housewife |
81 |
64.33-100.7 |
73.6 |
Number women with/without conception |
With conception |
103 |
82.2-122.7 |
93.6 |
Without conception |
7 |
4.1-17.08 |
6.4 |
Use of Contraceptive |
Yes |
49 |
36.25-64.78 |
44.5 |
No |
60 |
45.79-77.23 |
54.5 |
The mean age at marriage was found to be significantly higher among males (25.01±0.57 years) than females (21.03±0.43 years) (p<0.05). Similarly, the mean age at first child birth was also found to be significantly higher among males (26.34±0.56 years) than females (22.35±0.40 years) (p<0.05). The category-wise mean differences in age at marriage (t-value=5.526; d.f., 199) and age at first child (t-value=5.740; d.f., 199) among informants and informant’s husbands was observed to be statistically significant utilizing t-test analysis (p<0.05). Age-specific mean differences in age at marriage and age at first child among tribal Lepcha informants and their husbands are depicted in Figure 1. The results of a two-way ANOVA test showed that differences in mean for variables age and gender with dependent variables age at marriage (F=1.036; df= 24; p>0.05) and age at first child birth (F=1.136; df=23; p>0.05) are statistically not significant.
 |
Figure 1: Mean and the standard errors of the age at marriage and age at first child birth of the women informants and their respective partners |
The fertility and mortality measures in terms of socio-economic variables among Lepcha tribal women are depicted in Table 2. The distribution of mean values was observed to be among women with primary education in live births (3.28± 0.32), surviving children (3.14± 0.31) and number of dead children (1.33± 0.33). The mean differences in different categories of live births (F=5.088; p<0.05) and surviving children (F=4.040; p<0.05) with respect to education of women is statistically significant utilizing ANOVA. The mean differences in different categories of income and occupation in terms of live births and surviving children were observed to be statistically not significant (p>0.05). Further, the mean differences in dead children were observed to be statistically not significant in income, education and occupation among Lepcha tribal women using ANOVA (p>0.05).
| Table 2: Fertility and Mortality status with respect to socioeconomic variables of Lepcha tribal women in Dzongu, North Sikkim |
| Socioeconomic variables |
95% CI |
Mean live births ±SE |
Mean surviving children ±SE |
Mean dead children ± SE |
Education |
Primary |
19.4-41.6 |
3.28± 0.32 |
3.14± 0.31 |
1.33± 0.33 |
Secondary + |
38.8-68.1 |
2.21± 0.15 |
2.19± 0.15 |
1.00± 0.00 |
Illiterate |
12.2-30.9 |
3.05± 0.47 |
2.75± 0.41 |
1.25±0.25 |
total |
82.3-17.0 |
2.68± 1.61 |
2.57± 0.15 |
1.20±0.13 |
|
F-value |
5.088** |
4.040** |
0.453* |
Income |
Low |
44.9-76.1 |
2.81±0.22 |
2.71±0.21 |
1.29±0.18 |
Middle |
22.7-63-3 |
2.73±0.26 |
2.61±0.23 |
1.00±0.00 |
High |
4.1-17.0 |
1.67±0.23 |
1.56±0.24 |
- |
Total |
82.2-122.7 |
2.68±0.16 |
2.57±0.15 |
1.20± 0.13 |
|
F-value |
2.036* |
0.356* |
0.420* |
Occupation |
Government Jobs |
11.4-29.7 |
2.58± 0.467 |
1.05±0.247 |
1.00± |
Private/Business |
2.8-14.4 |
2.29±0.522 |
1.57±0.369 |
- |
Farmer/Housewife |
59.0-94.0 |
2.65±0.176 |
1.33±0.108 |
1.22±1.47 |
Total |
82.2-122.7 |
2.68±0.160 |
1.30±0.096 |
1.20±0.13 |
|
F-value |
0.537* |
0.830* |
0.229* |
| *p>0.05; **p<0.05 |
The distribution of family planning and use of contraceptives in terms of socio-economic variables are depicted in Table 3. The use of contraceptives was observed to be higher among women in the low-income group (44.4%), with secondary and above education (45.8%) and farmer/housewives’ occupation (45.0%). The results of chi-square analysis showed that frequency distribution differences in sub-categories of socio-economic variables were observed to be statistically not significant in terms of family planning and use of contraceptives among Lepcha tribal women (p>0.05) (Table 3).
| Table 3: Family planning and use of contraceptive with respect to socio economic variables among Lepcha tribal women in Dzongu, North Sikkim |
Socio-economic variables |
95% CI |
Birth control measures |
Family planning |
Use of contraceptive |
Yes (N=21) |
No (N=88) |
Yes (N=49) |
No (N=60) |
Education |
Primary |
19.1-41.6 |
8 (27.6) |
21 (72.4) |
14 (48.3) |
15 (51.7) |
Secondary + |
44.9-76.1 |
9 (15.3) |
50 (84.7) |
27 (45.8) |
32 (54.2) |
illiterate |
13.0-32.1 |
4 (19.0) |
17 (81.0) |
8 (38.1) |
13 (61.9) |
|
Chi-value |
|
1.902*; df= 2 |
0.544*; df= 2 |
Income |
Low |
48.4-80.6 |
12 (19.0) |
51 (81.0) |
28 (44.4) |
35 (55.6) |
Middle |
26.0-51.0 |
8 (21.6) |
29 (78.4) |
14 (37.8) |
23 (62.2) |
High |
4.1-17.0 |
1 (11.1) |
8 (88.9) |
7 (77.8) |
2 (22.2) |
|
Chi-value |
|
0.519*; df= 2 |
0 4.682*; df= 2 |
Occupation |
Government |
13.0-32.1 |
2 (9.5) |
19 (90.5) |
10 (47.6) |
11 (52.4) |
Private /business |
3.4-5.8 |
2 (25.0) |
6 (75.0) |
3 (37.5) |
5 (62.5) |
Farmer/ HouseWife |
63.4-99.6 |
17 (21.2) |
63 (78.8) |
36 (45.0) |
44 (55.0) |
|
Chi-value |
|
0.240* ; df=2 |
1.653* ; df=2 |
| Values are in parenthesis indicates percentages, *p>0.05 |
Discussion
Recent trends of fertility and mortality have shown a significant decline in the Indian populations [32]. The results of the present study indicated that the mean age at marriage and age at first child birth was found to be significantly higher among males than females
of Lepcha tribals of North Sikkim (Figure 1). Researchers have indicated that early age at marriage could also signify less autonomy, less reproductive awareness among women mostly residing in rural areas or vulnerable segments [11,25,34]. Further, the early age at marriage has significantly increased reproductive span, and prevalence of high fertility or conception, while delay in age at marriage means short reproductive phase and less chances of high fertility or reduced number of births. [6,11,13,25] The results showed that the number of live births and number of surviving children among the literate mothers were observed to be slightly higher than those of illiterate mothers (p>0.05) (Table 3). This could be due to the fact that educated women were found to have higher knowledge and awareness related to maternal and infant health, open towards visiting nearby healthcare centres, healthcare facility utilization and also frequently participated in health awareness programs conducted at different levels [3,6,18,19,23].
The adoption of family planning and contraceptive use in order to avoid unwanted pregnancies mainly focuses on providing nutritious food, medical facilities and education to their children, which they prefer to have in a smaller number of children with attainment of higher education in the population [3,5,6,11]. It is evident that poor maternal education (e.g., illiterate or no formal education) has less autonomy which affects decision of giving birth, negligence in taking good care of the infant and children are often observed, and even during pregnancy women give less importance to their own health conditions [3,21]. Several studies have reported malnourishment, morbidity and infants and child mortality are coupled with poor awareness, inadequate healthcare facility and/or negligence in availing healthcare facilities pre-natal or postpartum periods have leads to significant adverse reproductive outcomes (e.g., miscarriages, stillbirths and spontaneous abortion) and health complications [3,17,21]. Further, the results also indicated that education is one of the important factors affecting the fertility and mortality rates among Lepcha
tribal women of North Sikkim. The fertility rate was observed to be decreasing with the preference to have fewer children, provide better living, adoption of family planning and contraceptive use, which was also the reason for decreasing mortality rates in the population [5,6,23,27].
Several researchers have shown that socio-economic, socio-cultural and demographic conditions have significant influence on the fertility and mortality rate to a large extent in the populations. [7,13,21,24]. Moreover, adverse health conditions are accentuated by widespread poverty, illiteracy, malnutrition, environmental, personal hygiene, maternal-child health care practices and inadequate healthcare facilities among rural populations.[3,11,16,17] Poor socio-economic conditions accelerates food insecurity, ignorance, lack of appropriate infant and young child feeding practices, heavy burden of infectious diseases, undernutrition and poor hygiene or living conditions, sanitation, early age at marriage and conception, poor control over resource and allocation, inadequate decision making powers. [3,11,14-17,20,35] Present study indicated that women with infant mortality rates were found to be higher among the low-income groups and less in the middle- and high-income groups (p>0.05) (Table 3). The socio-economic distribution of the population was observed to be unequal with maximum numbers of informants from the low-income groups compared to the middle- and high-income groups, and results showed that income influences fertility and mortality among Lepcha
tribal women (p<0.05). Further, the mean live births and surviving children of women belonging to middle- and higher-income groups are found to be significantly higher than that of women from low income groups (p<0.05) (Table 2).
It is attributed to better nutritional status, medical and healthcare facilities which could be easily afforded by the higher income groups than low income groups, and improvements in socio-economic conditions are directly associated with standard of living, which contributed to having fewer children, thus bringing down the fertility and mortality in population. [3,5,11] The results indicated that majority of the Lepcha tribal women irrespective of socio-economic groups (e.g. income and education) reported to use contraceptives (e.g., oral pills and copper-T) (Table 3), and very few groups have opted for family planning (i.e., permanent sterilization) mainly attributes to easy availability of modern types of contraceptives, which are either provided by the healthcare providers and/or are easily available over the counter. The adoption of traditional contraceptive methods is not prevalent among the Lepcha
tribal women and the women mostly sensitized about family planning and contraceptives uses were chiefly assisted by village level healthcare workers (e.g., ASHA and Anganwadi workers) during the time of conception till the delivery of child, and even after that which prevents birth complications or infant mortality. Furthermore, researchers have confirmed the effective use of contraceptive in order to reduce/control the family size, increase the birth spacing, risk of unwanted pregnancies and mortality, induced abortion and adversely affected women health and also thus influencing the fertility rate in population. [5,6,11,27,36]
Conclusion
The mean age at marriage of women is
increasing which may be due to the impact of education. The adoption
of family planning, health awareness programs, migration,
accessibility of medical facilities, education and income played
important roles in decreasing both fertility and mortality.
Moreover, present study has clearly indicated that socio-economic,
socio-cultural as well as biological factors have a significant
effect in decreasing the rate of fertility and mortality among
Lepcha tribal women. Additional attention must be given to women's
education, reproductive and health status, socio-economic condition,
employment generation, institutional participation and delivery of
healthcare facilities at community level in order to curve the
current demographic situation.
Recommendation
Fertility and mortality are observed to be decreasing globally, which may positively impact the rate of fertility as it also reduces infant mortality and maternal mortality, but at the same time it can make populations which are at threat of decline more vulnerable. Therefore, appropriate response and intervention programmes are necessary to the decline in fertility among such populations.
Acknowledgement
Authors are thankful to the study
participants as well as residents of the study area for their kind
cooperation during data collection. The extended help and
cooperation of the Department of Anthropology, Sikkim University is
also being acknowledged.
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