Even though maternal health care has occupied the centre stage in the global discourse on development, especially in developing countries since the Cairo International Conference on Population and Development 1994, India has a long way to go. Unsurprisingly, considerably wide variations exist between social groups, with the Scheduled tribes lagging behind the farthest. Research on the determinants of maternal health care among tribes, especially the particularly vulnerable tribal groups, points towards the need for qualitative studies in order to shed light on the context and nuances involved in the adoption or non-adoption of maternal health care services by tribes. In this context the present study investigates the determinants of antenatal care and institutional delivery among Reang women, a particularly vulnerable group residing in the North-eastern state of Tripura. We adopt a mixed method approach for the study and collect both quantitative and qualitative information from 50 Reang women and 50 Reang men (the husbands). Quantitative data is collected using a pre-coded schedule structured along the lines of the Demographic and Health Surveys. The qualitative aspect focuses on the role of the geographical terrain, importance of male involvement in antenatal care, role of the local Accredited Social Health Activists and overall health seeking behaviour of the Reang tribe. Results reveal that Reangs lag behind in required number of ANC visits (42%) and required number of tetanus toxoid injections (61.2%) vis-à-vis the average for all rural tribes of Tripura, the figures being 47% and 82%respectively for the latter. Economic factors are overwhelmingly important in the adoption of full ANC and institutional delivery compared to knowledge, education and autonomy variables. In-depth interviews highlight the importance of male involvement especially in the context where the monetary resources are largely held by them as also in navigating through the formal health system. Our study also brings out the critical importance of local ASHAs among tribes, with nearly every Reang woman depending on them as access point to the formal health care delivery system.

1. Antenatal Care UtilizationAmong Particularly Vulnerable Tribal Groups:
ACase Study of the Reangs of Tripura
PRESENTED BY: ANINDITA SINHA
19TH ANNUAL CONFERENCE AND NATIONAL SEMINAR
OF THE NORTH EASTERN ECONOMIC ASSOCIATION
23nd and 24rd March, 2018
NEHU, SHILLONG

2. MATERNAL HEALTH IN INDIA AND
STATES:
FEW QUICK FACTS
 India’s performance in the area of maternal mortality is
distressing. MMR stood at 167 per 100,000 live births
during 2013, revealing a huge shortfall from the stated
target of 109 maternal deaths per 100,000 live births by
2015
 Assam revealed the highest MMR in India at 328 maternal
deaths per 100,000 live births, much above the national
average for the same period. Indirect estimate of the
maternal mortality ratio for Tripura (Sinha, 2016) puts it at
around 229 per lakh live births, substantially higher than
the national average
 Official sources (SRS, NFHS) reveal significant regional
and social variation in maternal health indicators across
states with a broad North-South and tribal-nontribal divide
2

3. RATIONALE OF THE STUDY
 Maternal health care , especially among tribes
remains an area of concern in India
 Relatively little known about maternal health
indicators of particularly vulnerable tribal groups,
especially from the North-eastern region
 Existing studies have adopted a methodology
developed for culturally different populations;
greater need for contextualization and
qualitative studies
3

4. OBJECTIVES OF THE STUDY
1. To estimate the percentage of Reang women
availing antenatal care and its components
2. a) To examine factors associated with the
utilization of ANC, with special emphasis on
women’s autonomy variables
(b) To examine the efficacy of conventional
autonomy variables among Reangs and
comment on the importance of context in the
analysis of non- mainstream cultures
4

5. DATA AND METHODS (1)
 This study is based on data gathered from extensive
fieldwork in villages inhabited by the Reang tribe
residing in Gomati district, Tripura, from June to middle
of September, 2017.
 We adopt a mixed method approach for the study and
collect both quantitative and qualitative information from
50 rural Reang women and 50 Reang men (the
husbands) who had at least one live birth during the time
of the interview.
 Quantitative data is collected using a pre-coded
schedule structured along the lines of the Demographic
5

6. DATA AND METHODS (2)
 The qualitative information is generated through in-depth
interviews and focus group discussion with Reang
respondents and interviews with local health personnel
 Attention was directed towards role of the geographical
terrain, importance of male involvement in antenatal
care, role of the local Accredited Social Health Activists
and overall health seeking behaviour of the Reang tribe.
 The schedule and IDI with individual respondents were
mostly conducted at the residence of the respondent
 The interviews were conducted with the assistance of an
interpreter, who speaks both the Reang dialect Kau-Bru
and Bengali
6

7. MAIN FINDINGS
7

8. Socio-Demographic
Profile
8

9. FINDINGS
 Majority of the respondents interviewed are in
the prime childbearing ages, with 73 percent of
the Reang women aged between 19 and 35
years
 One-fourth of the women in the sample have
never attended school
 66 percent of the women were married at 18
years of age or above
 69 percent have two or less than two live
births.
 Nearly all women reside in nuclear families
and are Hindus by religion Table 1.docx
9

10. Antenatal care utilization among Reangs
10

11. 4 + ANC Visits
66.4
61.7
81.4
76.2
49.3
46.9
42
All-Tripura
Rural Tripura
Urban Tripura
All Non-tribes
All Tribes
Rural Tribes
Reangs** σ = 15.1
Source: Author’s calculations from NFHS 4 unit level data for Tripura, 2017 **
calculated from primary data
11

12. 2 TT INJECTIONS
0
10
20
30
40
50
60
70
80
90
100
Full TT injections
All-Tripura
Rural Tripura
Urban Tripura
All Non-tribes
All Tribes
Rural Tribes
Reangs**
σ = 12.8
Source: Author’s calculations from NFHS 4 unit level data for Tripura, 2017 **
calculated from primary data
12

13. Full IFA
17.9 17.2
19.7
13.5
20.3
21.3
25.8
0
5
10
15
20
25
30
Full IFA
All-Tripura
Rural Tripura
Urban Tripura
All Non-tribes
All Tribes
Rural Tribes
Reangs**
σ = 3.8
Source: Author’s calculations from NFHS 4 unit level data for Tripura, 2017 **
calculated from primary data
13

14. Complete ANC
14%
13%
18%
13%
12%
12%
18%
All-Tripura Rural Tripura Urban Tripura All Non-tribes
All Tribes Rural Tribes Reangs**
σ = 1.8
14

15. Correlates of Antenatal care utilization
among Reangs
15

16. Cross-tabulations of use and non-use of ANC
with socio-economic variables, percentages
Variables
ANY ANC
Chi-square valueNo Yes
Woman’s
education
Below Primary 44.4 47.8
0.030
(not significant)
Primary and
above
55.6 52.2
Total % 100 100
Woman’s
occupation
Agriculture 77.8 73.9
0.052
(not significant)
Services 22.2 26.1
Total % 100 100
Socio-economic
status
Low 66.7 50.2
0.683
(not significant)
High 33.3 49.8
Total % 100 100
16

17. Table: Spearman’s Rank Order Correlation
Coefficients: Antenatal Care and Selected Other
Variables
Variables 4 + ANC
(1)
2 TT
(2)
100 IFA
(3)
ANY ANC
(4)
Own house/Land -0.410* -0.676** - -0.567***
Related by marriage - - -0.314* -
RA Coercion - 0.435** - 0.473***
Major household
purchase
- -0.389** - -0.331*
Spending family
income
- -0.400** -0.397* -0.397**
Mobility - - 0.333* -
Media Exposure - - - 0.334*
Place of Delivery 0.357** 0.380** - -
* Significant at 0.1 level ** significant at 0.05 level *** significant at 0.01 level
17

18. Correlates of ANC: The Upshot
 No significant differences in ANC utilization by
socio-economic characteristics among Reangs
 Significant association between ANC and
Institutional delivery
 Reproductive autonomy is found to be more
closely associated with utilization of maternal
health care as compared to other women’s
autonomy variables.
18

19. Correlates of ANC: The Upshot (Cont.)
 Women’s ownership of house and/or agricultural land
has a statistically significant inverse association with
ANC; in the context of Reangs the ownership of
land/house by a Reang woman is a reflection not so
much of her autonomy but of her poverty
 Major household purchases and decision regarding
spending the total household income have negative
association with ANC; case-wise study reveals the
husband is employed in the secondary or tertiary sector
and family is economically better off
In the context of overall low standard of living of the
Reangs and low educational attainment of women, the
conventional autonomy variables are not strong
indicators of utilization of maternal health care
19

20. Insights from in-depth interviews
 The IDIs shed light on several key aspects of the
processes and pathways through which various factors
influences ANC
 Though results from large scale studies establish a strong
relationship between women’s autonomy and ANC, we find
that context matters for women’s autonomy, and not all
kinds of autonomy has the same significance
 Economic factors, though not statistically significant, but as
revealed by in-depth interviews are overwhelmingly
important in the adoption of full ANC and institutional
delivery compared to knowledge, education and autonomy
variables.
 Interviews with men indicate that educating them could
also play an important role in increasing the use of ANC
20

21. POLICY IMPLICATIONS
21

22. POLICY IMPLICATIONS
 Key implications for research and policy making in
maternal health care among tribes:
1. Continued emphasis of education of both men and
women
2. Appreciation of the economic factors involved in the
non-use of maternal health care vis-à-vis cultural
factors
3. Incorporating feedback from local ASHAs in the
formulation of future policies (a dedicated transport
system?)
4. Involvement of husbands in the process from the start
22

23. POLICY IMPLICATIONS
 Contextualization of autonomy indicators for
culturally distinct (tribal) societies
1. Refine women’s autonomy measures as
employed in standard DHS type
questionnaires
2. Include dimensions of gender role attitude
and broader measures of reproductive
autonomy to obtain a better understanding of
the nuances involved in the process.
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