CHAPTER ONE
INTRODUCTION
Promote the right of every woman, man, and child to enjoy a life of health and equal opportunity. Ensure that every pregnancy is wanted, every birth is safe, every young person is free from HIV/AIDS, every girl and woman is treated with dignity and respect. Because every one counts. Thoraya Obaid, Executive Director, UNFPA 1.1 BACK GROUND OF THE STUDY Bangladesh though a small country in area, is one of the densely populated countries in the world along with136.7 (BDHS 2004) million people having 953 ( national economic review 2007) persons per square kilometer. But it is a country of variety with different landscapes and waterscapes. The south- eastern hill tracts of Bangladesh including three districts Rangamati, Khagrachari, and Bandarban are the biggest abode of different tribal communities which occupy one tenth of our land and more than one percent of total population of the country. In Bangladesh there are approximately 45 tribal communities (MOHFW 2004) like Chakma, Marma, Murang, Khumi, Hajong, Monipuri, khashia, Garo, Mog, Rakhain, and the majority of them live in these hilly districts. The tribals are the economically backward ethnic group. They are food gathers, hunters, forestland cultivators, and minor forest product collectors. They lived in isolation with near to nature hence, called son of soil. Tribes constitute separate socio-cultural groups having distinct customs, language, traditions, marriage, kinship, property inheritance system and living largely in agricultural and pre-agricultural level of technology. The dependency on nature and impoverished economy affect population growth and control, literacy, sex ratio, pregnancy procedure, sexual and health care. In tribal people, interference of supernatural agencies is particularly strong in context of health and diseases. The different deities and spirits are connected with various types of disease. The communities have specific gods for their health and disease, for calamities, diseases of cattle, bite of snakes and dogs and so on. All these deities have their own respective sphere and field. Elwin (1955) noted various gods associated with children’s disease, cough, cold, blindness, madness, diseases of pregnant women, and so on. Propitiating the respective god associated with the disease either directly or indirectly through shamns can cure most of these diseases. The Bhopa and traditional healers occupy prominent place in the treatment of diseases. If the reason of illness is identified as evil-eye, sorcery or witchcraft, the tribals always would call their Bhopa instead of consulting a doctor, as they strongly feel that the doctor are quite helpless against such evil forces which can only be counteracted by Bhopa (Nagda, 1992). More than half (58%) of tribal women and 80 percent of children are suffering from anemia (NFHS-2). In tribals,

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problems of malnutrition contribute to poverty, illiteracy, lack of nutritional food and health education of the parents, family food habits etc .In sanitation environment and unsafe drinking water create a problem of diarrhea, dysentery, parasitic infections and skin diseases. The tribal people believe that when the menstrual period is delayed by a month, a woman is assumed to be pregnant. She does not take Mahua liquor. There is no restriction on her daily routine work. The delivery (Japa) is conducted in hut called Jopada. The hut is cleaned and pasted with cow dung in advance. The pregnant women, when labour pain starts, go to the hut. In case of any problem, during the pregnancy, they call traditional Dai of the community, and sometimes ANM and Doctor. Elderly ladies of the community help in conducting the delivery. The naval cord is cut by mother herself with the help of a Bamboo strip, knife and stone They prefer to cut the naval cord with a bamboo strip because it is more safe from infections (Nagda,1992).After cutting the naval cord, the stump is tied and mahua oil is applied. The mother is given a small quantity of mahua liquor and water mixed with haldi (turmeric) and gour (Jaggary) for drinking for about 2 days. They think that these drinks will bring out all harmful substances from the body of the mother. Mothers are advised to avoid sour foods and green vegetables because they could adversely affect health of the mother and the child. The colostrum is discarded and the baby is breast fed after one day of delivery. The child is breast fed upto 2-3 years. The supplementary food is given after 5-6 months. They do not stop breast-feeding during the sickness of the child. In the recent couple of years particularly after the Chittagong Hill Tracts Treaty, 1997, the lifestyle and socio-economic pattern is getting a gradual change. Besides males, women of these tribal communities are coming out of their hilly boundaries and getting involved in various kinds of jobs like non-tribal people of all other districts of Bangladesh From governmental organizations to NGOs, different privileges, incentives, quotas, and other development programs are being run targeting to promoting the socio-economic status these people. In Chittagong city, hundreds of thousands tribal female workers, most of them are from hill tracts, are engaged in different industries and enterprises for their livelihood. Of these workers, most of them are between the age range of 15-24 and that’s why some are adolescent, some grown up adult, some married and some are unmarried. These workers have little knowledge about proper reproductive health and as a result they suffer from many reproductive and sexual health problems. The trends of early marriage among them have a big impact on national population growth and on their physical and mental health as well. The ignorance of reproductive health care and services, and the environment surrounding them in their work places are the main factors for their poor reproductive health conditions. But the irony of fact is that these working females have hardly come under proper study regarding their reproductive health conditions and the relevant fertility trends among them and its burden on the country as a whole.

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This paper is aimed to study the reproductive health seeking behavior of the young female tribal workers of 15-24 years of age who are from the neibouring Hill Tracts i.e. three hilly districts called Rangamati, Khagrachari, and Bandarban, and who are currently carrying their livelihood working at different industries/ factories in Chittagong. The study is concentrated to see the availability of reproductive health services, reproductive health problems, RH awareness, socio economic status, migration factors, HIV/AIDS/STIs awareness, fertility preference of the tribal female workers in Chittagong focusing on the four elements of Reproductive health1. Family planning 2. Safe motherhood 3. Adolescent Reproductive Health and 4. HIV/AIDS/STIs awareness The study will also analyse the tendency of migration of the tribals and its implications urban population growth. As the sample population for the study are of 15-24 years, the respondents may be married or unmarried; adolescents or post adolescent. Whatever the group they belong to, one thing is sure that this period (15-24 years) is the most important time in human life. Because within this period, people go through a rapid biological, mental, and social changes and phases of life. Just after the onset of puberty, people make pathway to career: feel attraction for opposite sex; get married; reproduce child; think for life, and the tribal people are no more exception to these things. 1.2 SKETCH OF TRIBAL PEOPLE According to Encyclopedia Britannica, tribe is any of a variety of social units, including some defined by unilineal descent and some define by ethnic origin. Cultural anthropologists usually apply the term to a unit of social organization that is culturally homogeneous and consists of multiple kinship groups-such as the Family, lineage or clan-that prohibit marriages within themselves but endorse or require marriages with persons of other kinship groups. Most tribes are organized as unitary political entities, within which people share a common language and culture. Some tribes are spread across large territories, and individual members may never meet or know all of the others. Some are small groups, confined to a limited territory, some times a single little island within which every one know each other very well. What unites societies of such diverse scale as being “tribal” is their own sense of “being a single people” but anthropologists would add-the people that lacks the equipments of citizenship, a constitution, or a formalized legal system that would define them as a nation-state. Throughout most of the history of modern cultural anthropology, the terms tribe and primitive were usually linked; however in recent years, primitive has been avoided by most anthropologists because it appears to carry with it an unintended judgment of the moral or technological development of a people.

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Considerable debate takes place over how best to characterize tribes. Some of this debate stems from perceived differences between pre-state tribes and contemporary tribes; some of this debate reflects more general controversy over cultural evolution and colonialism. In the popular imagination, tribes reflect a way of life that predates, and is more "natural", than that in modern states. Tribes also privilege primordial social ties, are clearly bounded, homogeneous, parochial, and stable. Thus, many believed that tribes organize links between families (including clans and lineages), and provide them with a social and ideological basis for solidarity that is in some way more limited than that of an "ethnic group" or of a "nation". Anthropological and ethnohistorical research has challenged all of these notions. In his 1972 study, The Notion of Tribe, Morton Fried provided numerous examples of tribes, the members of which spoke different languages and practised different rituals, or that shared languages and rituals with members of other tribes. Similarly, he provided examples of tribes where people followed different political leaders, or followed the same leaders as members of other tribes. He concluded that tribes in general are characterized by fluid boundaries and heterogeneity, are not parochial, and are dynamic. Tribal people are loosely called indigenous people who according to the Program of Action of The International Conference on Population and Development (ICPD), have a distinct and important perspective on population and development relationships, frequently quite different from those of the populations with which they interrelate within national boundaries. In some regions of the world, indigenous people, after long periods of population loss, are experiencing steady and in some places rapid population growth resulting from declining mortality, although morbidity and mortality are generally still much higher than for other sections of the national population. In other regions, however, they are still experiencing a steady population decline as a result of contact with external diseases, loss of land and resources, ecological destruction, displacement, resettlement and disruption of their families, communities and social systems. The situation of many indigenous groups is often characterized by discrimination and oppression, which are sometimes even institutionalized in national laws and structures of governance. In many cases, unsustainable patterns of production and consumption in the society at large are a key factor in the ongoing destruction of the ecological stability of their lands, as well as in an ongoing exertion of pressure to displace them from those lands. Indigenous people believe that recognition of their rights to their ancestral lands is inextricably linked to sustainable development. Indigenous people call for increased respect for indigenous culture, spirituality, lifestyles and sustainable development models, including traditional systems of land tenure, gender relations, use of resources and knowledge and practice of family planning. At national, regional and international levels, the perspectives of indigenous people have gained increasing recognition, as reflected, inter alia, in the presence of the Working Group on Indigenous Populations at the United Nations Conference on

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Environment and Development, and the proclamation by the General Assembly of the year 1993 as the International Year of the World's Indigenous People.

1.3 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE TRIBAL PEOPLE IN BANGLADESH Tribal groups in Bangladesh have their own set of languages, social structures, cultures and economic activities. They are at varying level economic and education development. They also live in sparsely populated and difficult to access terrains such as forests and hilly regions. Whatever the population they differ in their social organizations, marital customs, rites and rituals, food and other customs from the people of the rest of the country. Most of the tribal people speak in Tibeto-Burman tongues.

Tribal population: In 1991 there were about 1.2 million which is about 1.13 per cent of the country’s total Population. Tribal forums claim about 2.5 million as the current population size. Assuming a decadal growth rate of about 1.47 the current estimated tribal population based on 1991 Census, would be about 1.9 million. Proportion of

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tribal population in the 64 districts varies from less than one per cent to about 55.6 percent in Rangamati district in Chittagong Hill Tracts (CHT). Khagrachhari (48.9 %) and Bandarban (48 %) are the other two districts in CHT accounting for sizable tribal population. According to 1991 Census about 82 per cent of tribal were living in rural areas and 18 per cent in urban areas. Very high proportion of tribal follows Buddhism (37 %), followed by Hinduism (21 %), Islam (18 %), Christianity (11 %) and other belief system (13 %) (Census 1991). They speak a variety of languages, have their own distinct cultures and bound by their own customary laws.
Table 1.1: Distribution of Tribal population by religion, 1991

Religion Total % Muslim Hindu Buddhist Christian Others

Population Both sex Male 1205,978 79,693 100.0 100.0 18.0 18.4 21.2 21.0 36.7 36.9 11.0 10.8 13.1 12.9

Female Both sex 78,507 988,354 100.0 100.0 17.6 14.4 21.3 22.5 36.5 35.8 11.2 12.2 13.3 15.1

Rural Male 74,807 100.0 14.5 22.4 36.2 12.1 14.9

Female 73,639 100.0 14.3 22.7 35.5 12.4 15.2

In Bangladesh there are about 45 tribal communities and the majority of them live in CHT. Table 1.2 : Name of tribal communities and districts where they are found in Bangladesh

sl Tribe
1 2 3 4 5 6 7 8 9 10 11 12 13 14

Districts
Rangmati, Sylhet Kustia, Natore, Jinaidaha, Khulna, Josore Mymensingh, Sherpur, Jamalpur Bandarban Sirajganj, Chapainababganj Dinjapur, Rajshahi Bandarban, Cox’s Bazaar Rangmati, Khagrachari, Bandarban Mymensingh, Sherpur, Jamalpur Mymensingh, Tangail, Sherpur, Netrakona, Gazipur, Rangpur, Sylhet, Sunamganj, Moulabi Bazaar Rangmati Mymensingh, Sherpur, Netrakona, Sylhet,Sunamganj Sylhet Moulabi Bazaar, Sylhet, Sunamganj

Assam Bagdi Banai Bawam Bedia Bhumiji Chak Chakma Dalu Garo Gorkha Hajong Kharia Khasi

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15 16 17 18 19 20 21 22 23 24 25

Bandarban and Rangamati Sylhet Dinajpur, Rajshahi, Gazipur Bandarban Mymensingh, Tangail, Sherpur, Netrakona, Gazipur Rajshahi, Sylhet Rajshahi, Chapainababganj Rangamati, Bandarban Rajshahi, Dinajpur, Bogura Rajshahi, Dinajpur, Pabna, Sirajganj, Bagura,Jaypurhat Dinajpur, Rajshahi, Nogaon, Bogura, Chapainababganj, Rangpur, Panchagargh, nature, Thakurgaon, Pabna 26 Manipuri Moulabi Bazaar, Sylhet 27 Marma Rangamati, Bandarban 28 Munda Dinajpur, Rajshahi, Nogaon, Bogura, Chapainababganj, Rangpur, Panchagargh, Natore, Thakurgaon, Sylhet 29 Muriar Rajshahi, Dinajpur 30 Mro Bandarban 31 Mushohor Rajshahi, Dinajpur 32 Oraon Dinajpur, Rajshahi, Nogaon, Bogura, Chapainababganj, Rangpur, Panchagargh, Natore, Thakurgaon, Pabna 33 Pahan Rajshahi 34 Paharia Dinjapur, Rajshahi, Nogaon, Bogura, Chapainababganj, Rangpur, Panchagargh, Natore, Thakurgaon, Pabna 35 Pangkho Bandarban 36 patro Sylhet 37 Rai Rajshahi, Dinajpur 38 Rajbongshi Mymensingh, Rajshahi, Gazipur, Dinajpur, Tangail, Khulna, Josore, Faridpur, Kustia, Dhaka, Sherpur 39 Rajuar Rajshahi 40 Rakhain Cox’s Bazaar, Barguna, Patuakhali 41 Santal Dinjapur, Rajshahi, Nogaon, Bogura, Chapainababganj, Rangpur, Panchagargh, nature, Thakurgaon, Sylhet, CHT 42 Singh Pabna 43 Tanchangya Rangamati, Bandarban, Khagrachari 44 Tripura Rangamati, Bandarban, Khagrachari, Sylhet, Rajbari, Chandpur, Comilla, Chittagong 45 Turi Rajshahi, Dinajpur Source: Social Assessment and Tribal Health Nutrition and Population Plan for the HNP Sector Program (2005 to 2010)

Khyang Khondo Khotrio Barman Khumi Koch Kole Karmarkar Lushai Mahali Mahato Malo

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General Features of Chittagong Hill Tracts (CHT) : Chittagong Hill Tracts (CHT) the only extensive hill area in Bangladesh lies in southeastern part of the country (between 21025' North to 23045' North latitude and between 91054' East to 92050' East longitude) bordering Myanmar on the southeast, the Indian state of tripura on the north, Mizoram on the east and chittagong district on the west. The area of the Chittagong Hill Tracts is about 13,184 sq km, which is approximately one-tenth of the total area of Bangladesh. CHT is the habitat of several ethnic groups. All of them have their own language and culture. The Chakmas are the largest ethnic group in respect of population. The Chakmas belong to Mongoloid race. They have their own language and script. The second largest community in respect of population is Marma. The Marmas are found mainly in Bandarban District. The other ethnic groups are Tripura, Tanchangya, Chak, Murong, Khumi, Boam, Lushai, Pankho and Khyang. The main occupation of the people of Chittagong Hill Tracts is agriculture. The Jhum cultivation is the traditional system of cultivation in Chittagong hill Tracts. Some of the smaller tribal communities are still animists. Land is owned communally. Men and women work in the field and engage in various livelihood activities. They have been depending on the traditional medicine men for their health. Local beliefs and customs influence what food is consumed during pregnancy and given to newborn and children. Hence, tribal communities in Bangladesh cannot be clubbed together as one homogenous group. The socio-economic needs, health-seeking behavior, perception of family planning, practices affecting nutritional intake and aspirations vary from one tribal community to another. Reach of development programmes are not even. Same can be said of health, population and nutrition services. Tribal women are less educated compared to their male counterparts as well as compared to national figure of 32.4 per cent in 1991 Census. Literacy level among various tribal communities is also uneven. From the programme point of view diversity of tribal community in a geographically contiguous area introduces another challenge. It would not be uncommon to find in one mouza one finds four different tribal communities speaking four different languages, practicing four different religions, varying levels of development, variations in educational attainment and having their own sets of worldview. The biggest festival for the Chittagong Hill Tracts is called Boi-Sa-Bi. The Tripura call this festival Boishuk, the Marma call this festival Sanggrai and the Chakma call this festival Bizu. Through this festival People of the Chittagong Hill Tracts observe the Year Ending (31st of Chaitra of Bengali year) and they welcome the New Year (1st Boishakh of Bengali year). The Chittagong Hill Tracts, combining three hilly districts of Bangladesh, were once known as Korpos Mohol, the name used until 1860.In 1860 it was annexed by the British and was made an administrative district of Bengal. As of today, it is a semi autonomous region within Bangladesh comprising the districts, namely, Chengmi [Hagracuri (Khagrachari) Hill District], Gongkabor (Rangamati Hill District), and Arvumi (Bandarban Hill District). During the 1970s and 80s, there were attempts by the Government to resettle the area with Bengali people. These 8

attempts were resisted by the tribals, who, with the latent support of neighboring India, formed a guerilla force called Shanti Bahini. As a result of the tribal resistance movement, successive governments turned the Hill Tracts into a militarised zone.

Picture 1: Murma women are celebrating their traditional Sanggrai festival on the occasion of 1st Baishakh of Bengali new year. Chittagong Hill Tracts Treaty, 1997: The Chittagong Hill Tracts (CHT) peace accord was signed on December 2, 1997 in Dhaka at the Prime Minister's office between the government and the Parbatya Chattagram Jana Sanghati Samity (PCJSS). However, some hill tribe sects and organisations have rejected the accord. Under the framework of the constitution of Bangladesh and having fullest and firm confidence in the sovereignty and integrity of Bangladesh the national Committee on CHT Affairs, on behalf of the government of the People's Republic of Bangladesh and the Parbattya Chattagram Jana Samhati Samiti, on behalf of the inhabitants of the Chittagong Hill Tracts, with an objective to elevate political, social, cultural, educational and financial rights and to expedite socio-economic development process of all citizens in CHT. The tribal people both men and women in the recent years especially after the landmark treaty, are migrating to different cities particularly to Chittagong for a better prosperous life. They are getting habituated to modernization and bringing changes to life. Besides this, such trend of migration is imposing heavy urban population growth.

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1.4 RATIONALE Tribal people of Bangladesh are the most disadvantaged individuals in the country socially, politically, economically and of course as per health. Though the Chittagong Hill Tracts covers almost one-tenth of country’s whole territory and the tribal people are more than one percent of total population, but very little information about their reproductive health, health services, and sociodemographic conditions is available. However, changes and improvement in their life style is being observed in the recent couple of years as they are getting educated, taking multi-dimensional professions, showing interested in urbanization, changing their way of life etc. Particularly after the Peace Treaty, 1997 thousands of tribal poor workers are coming to Chittagong city, selling labors at various industries and factories and hoping for a better future. Reproductive health condition of women in our country is very poor. At present, thousands of tribal female workers especially of 15-24 year old who are the prime reproducers are engaged in different working environment. Though some interventions have been so far conducted by GoB and national and international NGOs to explore their reproductive health status of tribal people as a whole, but information about how the migrated female tribals are keeping their reproductive health is still far behind. For this reason this study is conducted to assess the knowledge, attitude and practice of reproductive health by these workers especially on the ground of family planning, safe motherhood, adolescent reproductive health, and HIV/AIDS/STIs. And of course the study will follow exploring some possible strategies to be developed to ensure every tribal pregnancy wanted, every birth is safe, every young tribal worker is free of HIV/AIDS, and each of them is treated with dignity and respect. Because reproductive health of every tribal girl counts. 1.5 STATEMENT OF THE PROBLEM Reproductive health belongs to basic human rights for human beings especially for women. In Bangladesh tribal people are no more thought to be discarded or neglected sect. With the gradual changes of socio-economic infrastructure of the hilly regions, these tribal people are getting engaged in all the socio, political, economic, and administrative sectors of Bangladesh. Lots of tribal women are also coming out of their secluded regions to city like Chittagong for a better life. In Chittagong, thousands of tribal women mostly of aged between 15-24 years are working at different factories. But reproductive health is a life cycle process. People of all age, sex, and race need to reproductively be healthy. Knowledge, attitude, and practice of RH issues especially safe motherhood, family planning, HIV/AIDS/STIs, and adolescent reproductive health of these young tribal females are still hardly known. Because no wider scale research addressing them has yet been undertaken. And this study is mainly aimed to address this very significant issue.

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1.6 OBJECTIVES OF THE STUDY This study focused on the following objectives



To assess the reproductive health seeking behavior among young female tribal workers (aged 15-24) in Chittagong.



To assess the knowledge on family planning, safe motherhood and HIV/AIDS/STIs among young female tribal workers (aged 15-24) in Chittagong.



To

assess

attitude

on

family

planning,

safe

motherhood

and

HIV/AIDS/STIs among young female tribal workers (aged 15-24) in Chittagong.


To assess the age specific fertility among young female tribal workers (aged 15-24) in Chittagong.

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CHAPTER TWO
REPRODUCTIVE HEALTH OF THE TRIBAL PEOPLE
Where there is smoke there is fire ---English proverb

Numerous studies were conducted on the health situation of the tribal people both globally and nationally, which are mainly focused on nutritional status, safe drinking and safe sanitation practices. Some studies on the reproductive health situation of the tribes which mainly include fertility, antenatal care, and prevalence of RTI’s etc. In the early part of this chapter an overview of Health status of the tribal community is given, next an overview of reproductive health status and lastly Bangladeshi tribal situation is given. 2.1 HEALTH OF TRIBAL COMMUNITIES Tania D. Karmaker, V. Sampathkumar s. Jeyalakshmi & Abel R in their study of Nutritional Status of Tribal women in Bihar “found that the majority of the tribes of Bihar were Hindus (99.6 %). Among the different tribes Santal (59.0 %) was the largest group. They were followed by Bhoomij (25.2%) and Mahalli (11.7 %). Birhor tribe was the smallest group (4.1%) Over 96.0% of the tribal women were illiterates engaged in agricultural manual work (97.3%). Table I shows the demographic characteristics of tribal women, in this population 36.0% experienced at least one abortion. The percentage of tribal women with four or more liking children was high (25.7%). Around 19.0% of the tribals had one or more child deaths. In this study it was found that if < 145 cm is taken as a cut –off point for short stature then 23.9% of the tribal women of this study can be termed as short statured. Similarly if