Prior studies have examined reproductive health mainly from a demographic perspective, as the outcome of various economic (Crane, 2005; Danilovich, 2010; Jayasundara, 2011; Pillai & Gupta, 2006) and social factors (Wang & Pillai, 2001). This study uses a sustainability perspective to examine the effect of ecological or environmental as well as social and economic factors on the reproductive health of tribal populations in India. With a view to understanding the impact of ongoing environmental degradation on the reproductive health of marginal women in developing nations, this study proposes a theoretical model explaining the strong correlation between social, economic, and ecological factors and reproductive health mediated by power (Salehin, 2016). This study is particularly significant in view of the marginalization and exclusion of tribal or indigenous ethnic groups in India that results in disparities between tribal and non-tribal populations and the lack of prior research on the effect of socioeconomic factors on the reproductive health condition (Salehin, 2015, 2016). This article will discuss the result of analyzing the proposed theoretical model (Salehin, 2016) using data collected through a national survey in India (National Family Health Survey [NFHS], 2009) with a view to investigating the impact of social, economic, and ecological factors on the reproductive health of tribal women in India.
The theoretical model for tribal women's reproductive health proposed in the current study ascertains correlations between social, economic, and ecological factors and reproductive health mediated by power (Salehin, 2016). The current study theorizes that tribal women's power stems from economic, social, and ecological factors and regulates the flow of energy or resources across the whole system, resulting in a significant effect on their reproductive health through its influence on their reproductive decision-making capacity (Salehin, 2016). Using Sen's capability approach (1979, 1992), the current study's theoretical model identifies two dimensions of tribal women's reproductive health: reproductive well-being and reproductive capability.
The proposed model of this study also utilizes Giddens's (1984) theory of structuration to explain power as the central component of social relations based on the social structure of the respective human agency, such as a particular tribal group. In tribal societies, social structure is guided by traditional customs that strongly influence the social relationship between men and women. Thus, the extent of power tribal women enjoy is reflected in their decision-making capacity regarding reproductive well-being and reproductive capability. In brief, the theoretical model of this study explains the aggregate effects of economic, social, and ecological factors on the reproductive health of tribal populations in India from a sustainability perspective (Salehin, 2016). Hypotheses with respect to the association of reproductive health with social, economic, and ecological factors and with power will be discussed in the following section.
Economic opportunities are expected to strongly influence women's reproductive health by creating a milieu in which women can empower themselves and consequently can have more control or power in the reproductive decision-making process. Prior studies suggest the strong influence of women's employment status on their reproductive health (Sunil & Pillai, 2010; United Nations, 1987). Women's income and employment opportunities can be influenced by their occupational sector, educational achievement, and access to institutional support that strongly influence their reproductive behavior and health. Based on these assumptions, hypothesis H1 on economic factors and reproductive health of tribal women is proposed: Economic opportunity has a significant positive effect on tribal women's reproductive health and power.
Social factors such as marriage practices (Chakravarty, Palit, Desai, & Raha, 2005), social status (Mann, 1996; Sikdar, 2009), education (Cochran & Farid, 1989; Martin, 1995), and health and hygiene practices (Ali, 1994; Chaudhuri, 1994) contribute to tribal women's reproductive health. Some of these sociocultural factors such as education and age at first marriage strongly influence age at motherhood and fertility rate, which in turn eventually influence the power of tribal women by modulating their status in the family (Basu, 1995; Sunil & Pillai, 2010). Educational achievement enhances the status of women in the family, resulting in increased power in the reproductive decision-making process (Cochran & Farid, 1989; Martin, 1995; Sunil & Pillai, 2010; United Nations, 1987). Based on these assumptions, the following hypothesis H2 on social factors and reproductive health of tribal women is proposed: Social opportunities of tribal women will have a significant positive effect on their reproductive health and power.
Tribal women's reproductive health is strongly associated with the environment and surrounding ecology (Chaudhuri, 1994). Ecological resources comprise input from the physical and social environment that may vary among tribes in different terrains (Maharatna, 2005). The correlation between ecological resources and reproductive health is mainly based on tribals' dependence on their surrounding ecology for food and nutrition (Ali, 1980; Patel, 1985). The influence of ecological resources on reproductive health can be mediated by the power held by tribal women because their vital role in the forest-based economy influences their level of power and decision-making capacity. Changes in the physical environment of tribal habitats may result in changes in food source, nutrition status (Basu, 1995; Beck & Mishra, 2011), and occupational pattern and may thereby affect tribal women's reproductive health. The predicted associations between ecological factors and reproductive health are expressed by hypothesis H3: Ecological resources have a significant positive effect on tribal women's reproductive health and power.
In the proposed theoretical model, tribal women's power is sustained in social relations subject to the tribal social structure (Giddens, 1984). Power is based on human knowledge and activity that are guided by the community's laws, rules, and customs. Within the power relation, women experience the freedom to decide their opportunities including those related to reproduction. Hence, power determines women's ability to make decisions for their own well-being including economic and reproductive expectations. The theoretical model of the current study assumes that the power of tribal women is the outcome of the effects of social, economic, and ecological factors that directly influence their reproductive health. The predicted association between power and reproductive health is expressed as hypothesis H4: Tribal women's power has a significant positive effect on their reproductive health. Figure 1 presents the theoretical model of the current study.
Data Source and Sampling
The analysis was performed by using secondary data collected for the third National Family Health Survey (NFHS-3) of India. The NFHS is a large-scale, multi-round survey conducted in a representative sample of households throughout India (NFHS, 2009). The survey collects data on fertility, infant and child mortality, family planning practices, maternal and child health, reproductive health, nutrition, anemia, and utilization and quality of health and family planning services of India. Since 1992-93, three rounds of the survey have been conducted, including the NFHS-3 of 2005-6. The NFHS-3 surveyed a nationally representative sample of 124,385 women aged fifteen to forty-nine and 74,369 men aged fifteen to fifty-four from 109,041 households living in all twenty-nine states of India (NFHS, 2009). The current study analyzes the data collected from a subsample of married tribal women and corresponding households. The final sample size used in this study was N = 10,205.
Operationalization of Variables
Reproductive Health. Reproductive health is a composite score, which is obtained by adding responses from twelve different questions such as whether the respondent had ever "heard of sexually transmitted disease." These questions represent two subdimensions of reproductive health: reproductive health capability (RH Cap) and reproductive well-being (RH WB). Reproductive capability encompasses information related to the tribal women's current reproductive health and nutrition status, as well as their knowledge of HIV/sexually transmitted disease (STD). Reproductive well-being measures the tribal women's reproductive performance or outcome and behavior, as well as negative reproductive experience (if any). The total value for each dimension represents a cumulative reproductive health score. Lower RH Cap and RH WB scores indicate a lower reproductive health capability and lower reproductive well-being. Variables were recoded if necessary as dichotomous variables with a score of 2 for desired outcome and 1 for undesired outcome.
A tribal woman's RH Cap value is obtained by adding the values of her score on (a) body mass index (BMI), (b) anemia level, (c) knowledge of contraceptive methods, (d) knowledge of HIV, and (e) knowledge of other STDs. Sen's (1979, 1992) definition of well-being as the aggregation of a person's collective functioning was used to operationalize reproductive well-being. Thus, RH WB is a summation of (a) the total number of children born to the respondent, (b) whether the respondent ever gave birth to a boy or girl who was born alive but died later, (c) whether the respondent ever had a terminated pregnancy or miscarriage, (d) whether the respondent ever used any contraceptive method, and (e) whether the...