Reproductive Health Seeking Behavior of Tribal Women: A case study among PARAJA tribes of Laxmipur Block, Koraput district, Odisha, India.

Abstract

Reproductive Health seeking behavior of Tribal Women among PARAJA community was studied in the Laxmipur Block, Koraput district, Odisha. The study was carried out based on both primary and secondary data. Primary data on health seeking behaviour of tribal pregnant women was collected through field survey (interview, focused group discussion and census schedule) in Ranjitguda village of Laxmipur Block . About fifty pregnant women belonging to PARAJA tribe were interrviewed and their responses were analysed. . The secondary data on reproductive and child health was collected from the Community Health Centre of Laxmipur Block, Koraput and the data was analysed to assess the government facilities available as regards to reproductive health of tribal women, their access and acceptability to such facilities and the real status of reproductive health in the block inhabited mostly by PARAJA tribe. The study shows that the reproductive and child health schemes of the government are neither implemented in their true spirits nor the tribals reap the benefits of the schemes. The study reveals that absence of gender bias and no to abortion are two important reproductive health seeking behavior of tribal women of PARAJA tribe. It is observed that the methods of caring during pregnancy and particularly the neonatal and postnatal period are still dependent on the traditional knowledge and methods.

1. Introduction

Health is one of the important factors in determining the living conditions of every human being in the society irrespective of caste, culture and economic status. The health of an individual depends on his/her access to food, sanitation, water supply, housing, education and health care. All these are significantly controlled by the socio- economic conditions of the person. India is one of the few countries in the world where women and men have nearly the same life expectancy at birth. The fact that the typical female advantage in life expectancy is not seen in India because of the problems with women’s health. The health of women is intrinsically linked to their status in the society. Studies on status of women have revealed that Indian women are viewed as economic burden on the family despite their significant contribution to the family economy. Women have very little autonomy; first under the control of their fathers, then of their husbands and finally of their sons. The major part in a women’s life span is the reproductive period, which includes marriage, pregnancy, childbirth and contraception. This part of women’s life is highly compromised in Indian family due to many reasons. Tribal women’s are more vulnerable during their reproductive period because of their typical social setting and food habit. The review below depicts the health issues of women in general and tribal women in particular both in the international, national and regional context, and form the basis for the present study.

Views of various authors and their perspective towards women’s health are discussed below to understand and assess the status of reproductive health of tribal women. The last decade has seen an escalating interest in understanding the health of women. Gender is observed as a major axis of difference that affects health status, while class, race, and nationality are also interrelated in complex ways with health inequalities (Dyck et al., 2001). In the international arena, women’s health issues have taken center stage. An important message that emerges from the discussion and deliberation at different international fora on women’s health is that health is a human right and women’s rights are human rights. The understandable focus on maternal and child health and “safe motherhood” was expanded to include all aspects and stages of women’s lives and to encompass physical, mental, social, and economic health, or “safe womanhood” (Lewis and Keiffer ,1994). This increased interest in women’s health resulted in a plethora of meetings, publications, initiatives, and research agendas (Lewis, 1998). Feminist analyses emphasize the influence of structured inequalities based on gender – but also those pertaining to class, “race,” sexual orientation, and age – on women’s health. Health status and experience are understood as gendered phenomena. Gender is not equated with “sex difference” in this framework of understanding. Rather it refers to the socially and culturally constructed meanings around biological sex, which inform notions of femininity and masculinity and associated norms of behavior. Doyal (1995), for example, suggests that women experience both material discrimination and cultural devaluation that, respectively, affect their access to the resources necessary for maintaining a healthy life and threaten their emotional health. Drawing on international research, Doyal(1995) shows that what women do as mothers, daughters, or wives, whether in domestic, waged, or unpaid community work, affects their health and the way they manage health problems, sometimes detrimentally. Cross-cultural variations are shown, for example, in life- cycle concerns, disease incidence, and dealing with threats to health. Health status and access to health care statistics also show inequalities between women throughout the world and within particular polities and economies. Being healthy, she suggests, goes beyond subjective well being to being free from sustained constraints on achieving one’s potential and enjoying a satisfying life. This conceptualization of health is similar to the approach of the World Health Organization (1986). This view depicts how the condition of health among women varies from one geographical area to another, across different social strata ,and last but not the least how women mostly face their health problems sometimes detrimentally. But here emphasis has been given on how women should face their health problems head on in order to live a healthy and happy life.

The most important period in the life span of women being the reproductive period, which extends from menarche to menopause; is intervened by marriage, pregnancy, childbirth and contraception. However, these conditions are determined by socioeconomic and cultural factors and available cultural facilities. A broader approach to reproductive health means that women have the ability to reproduce and regulate their fertility, that is, they are able to go through their pregnancy and child health safely, that the outcome of pregnancy is successful in terms of maternal and infant survival and well-being; and that couples are able to have sexual relations free from the fear of pregnancy and contracting diseases. Such an approach seeks to link concerns about fertility and mortality at both the aggregate and individual levels, and to incorporate the sociocultural as well as biomedical aspects of reproductive health. Common reasons for reproductive health problems are: low social status, low educational level and lack of decision-making power among young rural women (Suman and Asari, 2001). Reproductive health also represents the overall health condition of a population. The reproductive role of women starts from the most attaining menstruation to the post menopausal period all through the process of gestation, birth, breastfeeding, and child-rearing places her at the focal point of a population’s reproductive health. Moreover, women are central to various social and economic activities in tribal communities requiring reciprocal interactions with the contributing factors of reproductive health. 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, which emphasizes increasing women’s economic and educational status, and as a consequence, women’s reproductive rights. Thus, reproductive health indicates the level of self-determination, women’s reproductive rights, and strength of tribal’s socio-political power. Social justice is also linked to the status of reproductive health of Indian tribal population as the right to have basic needs and opportunities for reproductive well-being of women are linked to their empowerment. The health status of the tribal population in India is very poor due to widespread poverty, illiteracy, malnutrition, absence of safe drinking water and sanitary living conditions, poor maternal and child health services and ineffective coverage of national health and nutritional services (Basu, 2000). Tribal mothers have high rates of anemia, and girl children receive less than the desired nutritional intake. Studies (Maiti et al., 2005; Ramana and Usha Rani, 2014) emphasize the need for proper understanding of the different health aspects of tribal women in order to suggest and implement relevant health measures. Adolescent girls are future for healthy and strong motherhood. But in the tribal area, their status is very poor and condition is quite tragic.. About 70-80% of the girls are anemic. Studies on reproductive health of adolescent girls (Rao et al., 2008; Brogly et al, 2007; Kibret, 2003; Prasad,1999)) indicate that both married and unmarried adolescent girls (aged 13-19 years) are at risk for various reproductive health problems including unwanted pregnancies, risks associated with early pregnancy, and STIs/HIV/AIDS and suggest comprehensive health education and promotion of safer sexual practices. Tribal adolescent girls with absolutely no educational background are highly vulnerable to various reproductive health problems stated above.

India has the largest concentration of the tribal population in the world. According to 2011 census, the scheduled tribe population in the country is 84.3 million, which constitutes 8.2 percent of the total population. The government has implemented many governmental and non-governmental policies and programs to reduce health problems among tribal women. However, they are yet to reap the benefits of these policies and programs (Swain, 2013; Kolay and Bairagi, 2013). Swain (2013) conducted a preliminary study on reproductive and child health (RCH) in four villages of Koraput Block and four villages of Jeypore block having mixed population of scheduled caste, scheduled tribe (Paraja,, Gadaba, Bhumia and Kondha) and Hindu population with a relatively higher literacy rate than the targeted PARAJA tribe in the present study, and suggested that Reproductive and Child Health (RCH) programme requires an ideological change in its structure for the benefit of the targeted community, and should include health education, particularly for women and girl child . The objectives of the present study is to understand why the tribal people, particularly the tribal women, are not getting the benefits of governmental (National Rural Health Mission (NRHM)) and non-governmental policies and programs relating to health issues. Therefore, we have taken a case study on PARAJA tribes of Laxmipur Block, Koraput district to answer the above question.

2. Study Area

The study was carried out in Laxmipur block of Koraput district, Odisha.

Figure 1: Study area ( Koraput district and Laxmipur block in Odisha, India)

Figure 1 depicts the study area. Koraput is one of the tribal dominated districts of Odisha and is surrounded by mountains, thick forests, waterfalls and many areas are inaccessible even today. The district has a total area of 8,807 sq km, and is bounded between 17^o 50" to 20^o 3" North latitude and 81^o 27" to 84^o 1" East longitude. The district headquarter is situated 2900ft above mean sea level while the Laxmipur Block with its headquarter at Laxmipur is situated at a lower height above mean sea level. The tribal heartland Koraput has fourteen blocks and in all the blocks the tribal population dominates. The major tribes found in Laxmipur block are Paraja and Kandha. The human development index (HDI) value and rank of the district is respectively 0.431 and 27. Considering the above attributes of Koraput district, the study was carried out in some sample villages, mostly inhabited by Paraja tribes, of Laxmipur block.

2.1 Data and Methods

The present study is based on information gathered through field survey among the PARAJA tribal women of Laxmipur block in Koraput district. The study village, Ranjitguda, was selected based on the population of PARAJA tribe. The major source of data for the present study is the data collected through questionnaire from the 50 women of PARAJA tribe (both pregnant and mother of new born babies) of the village Ranjitguda of Laxmipur block whereas the secondary data on RCH was collected from the Laxmipur Community Health Center. The methods adopted during the field survey are, interview schedule (Appendix-1), focus group discussion (FGD), observation and statistical analysis followed by interpretation. It may be mentioned that the sampled population of 50 tribal women had no formal education, which was observed from the questionnaire duly filled by the respondents and subsequently confirmed through FGD.

Tribal people have indigenous knowledge of medicine, which they often apply at the time of need. It is also important for them to understand the impact and benefit of modern medicine. Illiteracy, ignorance and high risk beliefs and practices, high level of poverty, inadequate and inaccessibility of resources are the important reasons for not achieving the goals set by the government for the benefit of tribal women. Therefore, to understand the level of acceptance of the tribal women to the various policies and programs implemented by the government and other NGOs, a focus group discussion is made involving all the 50 sampled women as well as some of their village leaders and representatives.

3. Impacts of Policies and Programs During Different Five-Year Plan Periods On Tribal Development

The Constitution of India has provided a number of privileges to the tribal community and embodies specific provisions as follows:

• Statutory recognition of tribal communities.
• Creation of scheduled areas for development of tribals.
• Special representations in the parliament, in the legislative assemblies and the local bodies.
• Special privileges in the form of reservation of a certain percentage of post in government services and seats in educational institutions.
• Recognition of the right to use local language for administration and other purposes and to profess one’s faith.

During 4^th Five Year Plan (1969-74), the government has given emphasis on a substantial increase in the out lay for family planning. In the year 1972, the Planning Commission constituted a “Task Force on Development of Tribal Areas” with L.P.Vidyarthi as Chairman. The task force observed that in spite of various kinds of investments by the state and central government for tribal development in successive plans, some of the teething problems of tribals such as primitive methods of agriculture, land alienation, indebtedness, adverse effect of industrialization, low rate of literacy, poor rate of health and nutrition etc, has not been solved. During fifth five-year plan, agricultural and allied sectors claimed the highest investment amounting 26% followed by education and health services, which accounted for about 21%. A National Program of “Minimum Needs” was introduced which included elementary education, safe drinking water, health care, shelter for landless and slum up-gradation. The strategy of sixth five-year plan period was to lay emphasis on consolidation of the gains of protective measures, programs of full employment, education and health services. Seventh Five Year Plan (1986-90) paid attention towards the rehabilitation of poor tribals and removal of tribal women backwardness. The 8^th Five Year Plan (1992-97) with motive of alleviating poverty and removing unemployment, and a safety net for those who would be affected by the structural adjustment programs had attempted to build in ‘the human face of adjustment’. The 9^th Five Year Plan (1997-2002) focused on empowerment of women in general and upliftment of socially disadvantaged section of society in particular. The 10^th Five Year Plan (2002-07) laid down an ambitious target of achieving a double per capita income in next 10 years. But the planning commission, after thorough evaluation, observed that the growth was lop-sided and did not benefit many people including SC, ST and minorities who still lacked the basic requirements for a decent livings in terms of nutritional standards, access to education and basic health and also to other public services such as water supply and sewerage. The 11^th Five Year Plan (2007-12) focused on the previous imbalances. The main elements of the strategy were a revival of agricultural growth. It tried to improve access to essential services in health and education (including skill development). Special attention to the disadvantaged groups and good governance at all levels; central, state and local was the main focus. The 12^th Five Year Plan (2012-17) seeks to reduce the poverty by 10% in the five-year period. In health sector, it has already set the target to reduce Infant Mortality Rate (IMR) to 25 and Mother Mortality Rate (MMR) to 1 per 1,000 live births, and to improve child sex ratio (0-6 years) to 950 by the end of the 12^th Five Year Plan. It also seeks to reduce total fertility rate to 2.1 and reduce under-nutrition among children to the half of the NFHS-3 levels. However healthcare is a major problem among women in tribal areas. Lack of food security, sanitation and clean drinking water, poor nutrition and high poverty levels aggravate their poor health status. Though good health care facilities like a good hospital or ambulance service (108) is available for the women who lives in city, it is neither accessible to small towns and suburban areas nor to tribal people living in remote areas. The government of India lunched National Rural Health Mission (NRHM) in April 2005 to provide effective health care to the rural population and its special focus was on 18 states with poor medical infrastructural facility. The NRHM, a link between villagers and health centers, aims at covering all villages through approximately 2.5 lakh village-based “Accredited Social Health Activities”(ASHA).

4. Scenario in Laxmipur Block

Table 1 shows that the number of registered pregnant women within first trimester and the number received 3ANC check up are less than the total number of pregnant women registered for ANC. Number of pregnant women in hypertensions and anemia (HB<11) are 381 and 271 respectively. Out of 385 deliveries at home only 17 cases were attended by SBA trained doctors/nurses/ANM. On the other hand, 369 cases of new born are attended by SBA trained doctors/nurses/ANM within 24 hours of home delivery. Although Janani Surakhya Yojana(JSY) is in vogue, not even a single mother has availed it after the delivery. Thus, it is a clear case of non availability of RCH facilities like JSY to the tribal women. Numbers of baby girls born are more than the number of baby boys. Number of deliveries made at institutions like PHCs, CHCs, and other public and private institutions are zero and suggest that tribal women prefer to deliver at home despite the facilities available at government and other private institutions. RTI/STI cases and Medical termination of pregnancy (MTP) are not happening where as spontaneous abortions are shown in the data. No complicated cases are treated at PHCs/CHCs. Not even a single case of family planning, laparoscopic sterilization, mini-laparoscopic sterilization, post-partum sterilization is observed in the block during the period of data analysis. This again suggests the apathetic attitude of the tribals towards the government run family planning programs or their disinterest for family planning. Women receiving post partum checkups within 48 hours after delivery and getting post partum checkups between 48 hours and 14 days are 847 and 597 respectively. Further, the analysis of data suggests that there are no NSV trained doctors in the block in any of the government /private institutions.

Table 1: Annual average statistics of Reproductive and Child Health (RCH) facilities at Laxmipur Block of Koraput district, Odisha (2011-2014)

(Source: Community Health Center- CHC, Laxmipur, Laxmipur Block, Koraput District, Odisha).

4.1 Village Study: Observation and Analysis of Health Issues

In order to understand the reproductive and child health facilities available and the functional mechanisms of health care facilitators, some case studies were conducted in the village Ranjitguda and the results are presented below.

4.1.1 Role of Anganwadi Worker, MPHW and ANM

An Anganwadi centre is located at Ranjitguda village and an Anganwadi worker is working in the centre. She takes care of pregnant women and children as well as of elders. She travels across different villages and identifies the pregnant mothers, and monitors their health progress. Besides keeping track of mothers’ health, she assists during childbirth. After the delivery, her responsibility increases as she monitors the health of the newborn baby and her/his mother, follows the schedule of vaccination and ensures nutritious diet for the newborn and also takes care of the primary education of the child.

Multipurpose health worker (MPHW) and Auxiliary Nurse Midwife (ANM) are playing a vital role in providing child and maternal health care in the villages. Normally, one MPHW and an ANM are attached to the Aganwadi centre, who visit the villages on last Thursday of every month. They take care of the whole immunization process of children. They also take care of the pregnant women and supply them medicines regularly. They also take the weight of the mother and the new born babies and monitor their health. It is observed that the weight of the pregnant women varies between 50-60 kg while the weights of the newborn babies are around 3kg. One case of jaundice in a newborn baby was detected during our field survey. The parents preferred to treat the baby indigenously while some other parents, when asked, replied that they take their babies to the district hospital in case of any disease. In case of a baby affected by jaundice, parents and elders avoid the presence of any yellow colour object around the baby.

4.1.2 Diet of Pregnant Mother

During first two months of pregnancy, most of the pregnant women regularly vomit and take very little food. In their breakfast they take rice, boiled pulses and a glass of gruel( mandia pej); during lunch they also take rice, boiled pulses and vegetable like beans, carrot, radish, and fried leaves, vegetables etc. At evening they don’t take anything. During dinner they again eat rice and curry. At times, some women take ripe papaya and banana and boiled eggs. Mixed flour (chatua), made up of corn, wheat, groundnuts and sugar etc., is supplied to the pregnant women by the respective anganwadi centers.

4.1.3 Diet of newborn babies

Tribal women agree that mother’s first milk is the best medicine for her baby, which is called colostrums (koso khiro). It is observed that, till six months the infant only takes mother’s milk. However, in case of any health problem or shortage of mother’s milk, they can go for substitutes like cow’s / goat’s milk. After six months, the baby is given the boiled ragi and rice.But now a days, they have learnt to provide some nutritional food like boiled rice, boiled pulses, mixed vegetable curry and pulses. Most of the mothers try to breastfeed their children up to the age of three.

4.1.4 Attitude towards Reproductive Health

A tribal lady when realizes that she is pregnant, she first reports the good news to her husband and then to her family members. She, however, feels little shy and shares the news with her close ones only. It is observed that 78% of the ladies get pregnant at the age of 17-18. After getting pregnant most of them consult the Anganwadi worker (in charge of the ICDS schools in the respective villages), elderly ladies, midwives, and relatives. Almost all of the pregnant ladies take prescribed medicines and regularly visit the Anganwadi workers. The complicated cases, identified by Aganwadi worker/ANM, are advised to consult the doctor at Community Health Center (CHC). Most of the parents wish for a baby irrespective of gender. Almost all of the pregnant ladies do heavy household chores such as washing clothes, cleaning the house, lifting buckets and carrying water containers on their heads. However, collection of fire wood and venturing into the forest is restricted during the pregnancy.

It is observed that, despite their desire to have nutritious food like milk, egg etc., they could hardly afford them due to their poor economic condition. There are a few cows and buffalos in the village, but they don’t use their milk as baby food or as the food for the mother. Because, they believe that the milk is only for the calf, and it as a sin to extract milk for their use. However, they are provided with incentives and monetary help by the government as prescribed for all the registered pregnant women.

The female members of the extended family, neighbours and midwives help during the delivery at home. However, as it is observed, they now prefer institutional delivery, and the Ambulance service (108) introduced by the government of Odisha facilitates it.

They mostly prefer normal delivery to caesarian and look forward to the delivery of a healthy baby. After the birth, the mothers feed their infants with the colostrums though it was not prevalent before. Out of the interviewed mothers of newborn babies, 40% agree that it should be given within one hour of delivery and 45% agree that it should be given within two hours of delivery. 30% of the mothers interviewed feel that the ideal weight of a baby is 2.5 kg while rests have no idea. In case of institutional delivery, the baby after reaching the home is immediately given warm water bath by her/his maternal grandmother. The disposal of placenta is a ritual after delivery at home but they skip the ritual in cases of institutional delivery. Among the delivery cases, 68% prefer to stick to the hospital/Anganawadi workers/ANM’s instructions as regards to delivery. The complication in milk feeding is observed in some of the study villages. In such cases, they eat papaya to counter it. On the other hand, none of the interviewed mother opts for breast-feeding.

Until seven days from the date of delivery no one touches the baby or the mother except the midwife. If someone does so they usually take a bath. The traditional midwives are preferred to guide the mothers of newborn babies. They are also given training for the modern methods by the District Headquarter Hospitals. A fire is burnt to provide comfort to both the mother and the child. The midwives sometimes apply massage to both mother and baby with karanja oil. The distilled liquor prepared at home or gifted by well-wishers, is given to the delivered mothers to relieve their pain around abdomen, pelvis and lower limbs. The boiled bamboo shoots are given to the postnatal mother at least for three months along with other foods. On 12 ^th day, the family members observe pollution rites. But till 21st day, no body touches the mother and the child. In case of diarrhea, 65% of the mother’s first preference is breast milk while 60% agree for ORS as the preliminary treatment.

Tribal ladies give importance to “Birth Spacing”, i.e. the time difference between two consecutive birth because of their busy engagement in household work and other economic activities to supplement their family income. However, most of them, interviewed, are shy in expressing their views and methods adopted for birth spacing. Nevertheless, they use modern methods of birth control. They, however, never go for abortion as it is considered a crime. The help of traditional medicine man/woman is very often sought, as they prefer to confide with them than to the modern health workers. However, the two children norm is popular and preferred among 94% of mothers. Help of hospitals is preferred over traditional healers by 80% of pregnant women. As against the query about women suffering from sexually transmitted diseases and Reproductive Tract Infections(RTI) 35% of the respondents answered ‘yes’

5. Conclusion

The study reveals that there exist various schemes for the tribal development as a whole and for the reproductive and child health in particular, both by the central and state governments. However, the schemes are neither implemented in their true spirits nor the tribals reap the benefits of the scheme whenever and wherever they are implemented. The role of ANM and Anganwadi workers is apparent in providing the help for reproductive and child health facilities. The study reveals that despite some of the facilities extended to them, tribal women never use the facilities. For example, they turn a deaf ear to the family planning and the associated provisions. The study further suggests that tribals are never biased towards gender. The diet of both mother and the child are specific up to certain period after the delivery. Birth spacing is given lots of importance by the tribal while abortion is never the case as it is considered a crime. The traditional method of caring during pregnancy, particularly during the neonatal and postnatal period, is still dependant on the traditional knowledge and methods.

Appendix-I

Interview Schedule

A. Safe motherhood & neo natal care

1. What is normal age of marriage in your village?
2. According to you, what should be the minimum age for getting married? What was your age of marriage?
3. How do you confirm the pregnancy? Whom do you inform?
4. According to you, maximum how many children a woman should give birth?
5. Did you see anyone for antenatal checkup (medical checkup by a health staff or doctor during pregnancy before delivery)?
6. How many months pregnant were you when you received the first antenatal care?
7. During pregnancy, how many times you take food and what food items you are taking?
8. Do you know about colostrum
9. How many kilograms should the new born be
10. Within how many hours, colostrum given?
11. Do you know about immunization to children and in which months which immunization is taken?
12. Do you have knowledge about the maternal death in your village? If yes. Reasons?
13. Up to how many months, only breast feeding should be given to the baby?
14. If the child has diarrhea, what is the preliminary treatment, breast milk should be given or not?
15. Do you know about ORS
16. According to you, how can pregnant women are prepared for safe delivery?
17. According to you what are the five cleanliness during the delivery time?
18. Do you participate in the meeting conducted by Anganwadi Worker?
19. Do you know about VHND & Mamata Diwas?
20. Do you know about ARI? How ARI is treated?
21. Who is taking care of baby in your absence?
22. Have you heard about RTI/STD? Is there anybody in your village suffering from these problems?
23. From whom do you receive help during the pregnancy? Who? What type of helps?

B. Integrated Management of Neonatal & Childhood Illness (IMNCI)

Neo- natal Care

1. According to you, If mother / child is suffering from diseases do you Prefer to continue breast feeding. If no, what is the fooding practice during that time?
2. If your child is suffering from disease where do you prefer for treatment?
3. Does your child suffered from diarrhea? If yes? Do you apply homemade treatment (ORS)

C. Early Child care and Protection

1. Do you measure your child's weight regularly? At present in which grade your child is.
2. In your absent who looks after the child at your home
3. According to you, how can you keep your child neat & clean?
4. According to you, how many hours a mother should spend with her child?
5. According to you, in which age the child should go to AWC?
6. Do you visit the AWC any time? If Yes? Purpose
7. Do you feel that your child is learning age appropriate education in the AWC? Why?
8. Do you feel that education through TLM will help the child's growth & development? How?
9. Do you attend any meeting in the AWC? Please Specify?
10. Are you aware of the Govt. schemes available in the AWC?

D. HEALTH WORKER FEMALE / ASHA

1. How many years you have been working as HEALTH WORKER FEMALE?
2. According to you, what is the variation in the rate of child death? Reasons?
3. According to you, the status of immunization coverage of children
4. How do Women/ men respond to Family planning?
5. Do all pregnant women possess card in the area you cover?
6. Do all mothers (with less than one year old child) possess card in the area you cover?
7. Referring complicated delivery cases to health centre or hospitals?

E. Anganwadi Centre

1. According to you, what are the three major problems facing your centre?.
2. Is there sufficient Teaching Training & Learning Materials (TLM) and playing materials in your centre for preschool children?

F. Interaction with Male Members

1. Do you ever take any initiative for health checkup?

2. In your family who take decision in this situation?

Acknowledgement :

One of the authors (MS) wish to express her sincere thanks to the authorities of Central University of Orissa, Koraput for encouragement. The authors wish to thank the villagers of the sample village and the staff of CHC, Laxmipur for their help during field work and sharing NRHM data.

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1. Faculty of Anthropology, School of Social Sciences, Central University of Orissa, Koraput-20

2. Department of Sociology, Utkal University,Bhubaneswar-751003