Exploring Maternal and Child Health Among Tribal Communities in India: A Life Course Perspective

India experiences high rates of maternal and infant mortality and morbidity, with tribal communities disproportionately affected. Tribal populations frequently live in unfavorable socio-economic conditions and deficient social health indicators, culminating in adverse health consequences. Using a life course perspective, this qualitative study explored risks over the life course that contribute to maternal and child health problems among tribal populations in India. Additionally, the study examined barriers to utilization of healthcare services during the pregnancy and postpartum periods. Data collection occurred between 2017 and 2019 through participant observation, key informant interviews (n = 7) and in-depth interviews (n = 68) and a focus group (n = 7) with tribal women from the Madia-Gond tribe in the Indian state of Maharashtra. Additionally, verbal autopsies were conducted with relatives of three deceased women and five infants from the tribe. Multiple risk factors operating at different socio-ecological levels and developmental stages of life were associated with maternal and child health problems among the tribe. These included adherence to traditional harmful practices, limited access to nutritional diet, women’s health neglected due to the double burden of domestic and professional labor, and a lack of accessible and well-equipped medical facilities. Inaccesibility stemmed from factors including extreme poverty, geographical isolation, and suboptimal healthcare infrastructure. There is need for provisions to promote access to care and to promote education and awareness centered on evidence-supported healthcare, particularly targeted towards expectant mothers. The implementation of nutritional support programs may help mitigate high maternal and child mortality and morbidity rates prevalent among tribal populations.


Introduction
Maternal and infant mortalities pose substantial challenges to global public health.The world suffers from an unexpectedly high burden of maternal mortality, with an overall estimated maternal mortality ratio (MMR) of 223 maternal deaths per 100 000 live births in the year 2020 (World Health Organization [WHO], 2023).Central and Southern Asia are one of the biggest contributors to global maternal mortality with an MMR of approximately 129 (WHO, 2023).In 2020, India recorded the second-highest number of global maternal deaths, with approximately 24,000 fatalities, ranking just below Nigeria (WHO, 2023).Similarly, India also has one of the highest global infant mortality ratios (IMR) standing at 40.7 deaths per 1000 live births (Ministry of Tribal Affairs, 2023).Tribal communities in India bear a significant burden, as they account for over 50% of all maternal deaths and IMR in the country (Dasra, 2016).The IMR among tribal children is 30% higher than the national average and 61% higher for tribal children under five (Dasra, 2016).The higher IMR and MMR observed in tribal populations can be attributed to disparities in social determinants of health such as education, adequate and trained healthcare workforce, access to care, and health financing (Dasra, 2016;Kumar et al., 2020).Inadequate healthcare infrastructure, limited access to essential services, malnutrition, and high disease prevalence, hinder overall health and well-being of tribal populations in India (Hamal et al., 2020).To illustrate, maternal and child healthcare services are mostly underutilized amongst tribal women, with only 10 % of tribal women receiving full antenatal care and only 18% of tribal women having institutional deliveries (Dasra, 2016).Tribal children were found to have a full vaccination rate of only 55.8%, whereas the national average stood at 62.0% (Ministry of Tribal Affairs, 2019).The elevated IMR in tribal communities can be partially attributed to the lower vaccination rates.
The presence of unfavorable social indicators in tribal populations is the result of long-standing discrimination and an infringement of rights of tribal communities.Tribal populations endure the most of systemic and structural marginalization within Indian society due to land disputes, socio-economic disparities, and cultural differences (Søreide, 2017).Social and geographic isolation adversely affects maternal and infant health in tribal communities (Hamal et al., 2020).Further, almost 90% of tribal people reside in rural areas (The Expert Committee on Tribal Health, 2023).Rural areas in India are characterized by numerous healthcare challenges, including limited access to quality healthcare facilities, subpar quality of primary health care, and ineffective training of rural healthcare professionals (Mohan & Kumar, 2019;Sabri et al., 2023).The intersectionality of belonging to a tribe, with low socioeconomic status, and living in a forest or a remote rural area compounds the disease burden, result in a quadruple challenge for maternal and child health care among tribal populations.This includes communicable and non-communicable diseases, malnutrition, mental health issues, and addictions, all exacerbated by inadequate health-seeking behaviors and healthcare infrastructure (Kumar et al., 2020).
The life course perspective is a useful framework for examining multiple factors throughout the life span that contribute to disparities in maternal and child health outcomes among the tribes.Current literature lacks comprehensive coverage and analysis of factors related maternal and child health in tribal populations in India.Moreover, there is a lack of qualitative literature that provides first-hand accounts and detailed descriptions of the hardships and challenges experienced by tribal women and children.This study offers valuable insights to practitioners regarding the specific gaps faced by rural, tribal women, and their children when it comes to accessing necessary healthcare services.By enhancing policy makers and practitioners' understanding of the conditions tribal people face, the findings from the study informs the development of essential infrastructure and initiatives aimed at reducing health disparities among tribal women and children.Therefore, the purpose of this qualitative study was to identify risks over the life course that contribute to maternal and child mortalities and morbidities from the perspective of primary healthcare workers, and women and families residing in tribal areas in India.Using a life course approach (Jones et al., 2019), this study collected data to gain insight into the sociodemographic, economic, cultural, and behavioral factors interwoven throughout women's life cycles.These factors play a crucial role in shaping maternal and child health outcomes and, in some instances, can lead to expected or unexpected tragic events, such as death.

Study Design, Setting, and Sample
This qualitative study, part of a mixed methods project (2017)(2018)(2019), aimed to understand poor maternal and child health (MCH) among tribal women and children in Bhamaragadh, one of the most socio-economically underdeveloped areas in the Indian state of Maharashtra.Bhamaragadh, home to the Madia-Gond tribes, faces isolation due to political insurgency and police conflict (Soreide, 2013).The region's challenges are compounded by dense forest coverage, limited mobile telecommunicatiaon connectivity, inadequate transportation, and regular power outages (Government of Maharashtra, 2023).As evidenced by poor MCH indicators including high maternal and neonatal mortality rates, the geographical location and limited resource accessibility, pose health challenges for Madia-Gond families (Kalkonde et al., 2019).This study used an integrated research paradigm for understanding women's lived experiences in Bhamaragarh.The process involved a phenomenological and narrative design with an interpretivist approach to explore MCH issues in the area.Data collection involved key informant interviews (n = 7), verbal autopsy interviews (n = 7), focus group (n = 1, with 7 participants), in-depth interviews (n = 68) and participant observation.Participants were selected using purposive sampling, with the sample including seven primary healthcare workers from the key informant interviews, eight family members of three deceased women and five infants from the verbal autopsy interviews, seven tribal women from a focus group and 68 tribal women participants from the in-depth interviews.
The key informants were eligible if they provided primary healthcare services to Madia-Gond tribal families in the study area.These included Auxiliary Nurse Midwives (ANMs; n = 3), General Nursing and Midwife (GNM; n = 1), Accredited Social Healthcare Activists (ASHAs; n = 1) and Multipurpose Workers (MPW, n = 2).The verbal autopsy interviews were conducted with immediate family members of deceased women or children from the Madia-Gond tribe.Only those families in which death of a mother or a child occured within the past year were selected for the interviews.The eligibility criteria for the focus group were (1) women from the Madia-Gond tribe and (2) recent (past year) delivery or currently pregnant.The eligibility criteria for women's in-depth interviews were (1) women from the Madia-Gond tribe and (2) have delivered a child within the past year.

Recruitment and Data Collection Procedure
For recruitment, the researcher (a trained Master of Public Health student) met with the Block Health officer of Bhamaragadh, who called a meeting of 19 health care workers from the three primary healthcare centers covering 24 tribal villages.The meeting with the workers involved sharing information about the study and getting their buy-in for assistance with identifying and consenting potential study participants.The researcher also stayed with the community for 80 days (April to June, 2019).During this stay, she closely observed the day-to -day activities of Madia-Gond women, including their access to MCH services in the community and maintained a diary.She contacted the participants at least a day in advance with the help of village health workers.On average, 3-4 interviews were conducted per day with participants from 1-3 villages, depending upon the proximity of the villages and number of participants available for the interview.Data collection in unapproachable or hard to reach villages involved a week-long stay in those villages for recruitment.
After obtaining oral consent, data was collected in-person at a private location using semistructured interview and focus group guides, with sessions lasting for approximately 60-90 minutes.The interviews and focus group were conducted in Gondi and Marathi language by the researcher.The primary healthcare worker who was trusted by women served as the interpreter for Gondi, the local tribal language.Drawing from the life course perspective (Jones et al., 2019), the questions in interviews and focus groups explored the factors or experiences and trajectory that shaped MCH outcomes for tribal populations.All the interviews examined factors on a continuum from mother's womb to birth -childhood -adolescence -married life -conception -delivery and in some cases to unfortunate deaths of woman.The key informant interviews elicited providers' perspectives in delivering healthcare services in the tribal region and their experiences and views about the social, behavioral, economic, cultural, and physical health conditions of women.The in-depth interviews and focus group for women explored socioeconomic, cultural, and structural barriers to MCH in the tribe, and access to and utilization of antenatal, intra-natal and postnatal care.The sessions also explored strategic approaches to prenatal and post-natal care of women and children in the tribal region.The sessions were audio-recorded, translated, and transcribed verbatim in English.All study procedures were approved by the Tata Institute of Social Science Faculty Ethics Committee.

Data Analysis Procedures
Data was analyzed using content analysis procedure (Bengtsson, 2016).The focus was on understanding the impact of multilevel factors such as socio-economic conditions, cultural practices, and prenatal to postnatal care on MCH in Bhamaragadh's tribal families.Using the life course perspective (Jones et al., 2019), the analysis identified multiple factors that influenced and affected Madia-Gond women such as being in their mother's womb to their birth -childhood -adolescence -early marriage -early pregnancy and multiple deliveries in underage period -delivery complications and sometimes to deaths.The researcher did not create a codebook a priori and used a data-driven approach to discover patterns and themes in participants' responses to the questions and follow up questions.Themes were systematically aligned with segments of the life-course and socio-ecological models.Triangulation from three qualitative sources (in-depth interviews, focus group, verbal autopsies) ensured the trustworthiness of the findings.

The Childhood Experience of Madia-Gond Girls
The risks experienced by Madia-Gond women starts from birth itself, with preterm births and low-birth weight babies during delivery being a prevalent phenomenon.Bhamaragadh's neonatal mortality is high, accounting for 12.4% of Maharashtra's total neonatal deaths (Saunik et al., 2017).

Socio-cultural Level
Impact of Traditional Childcare Practices: Traditional tribal cultural practices negatively impact the health outcomes of infants.For example, tribal women often bathe newborns believing they are covered in harmful fluids and dirt, risking infection and hypothermia for the baby (Priyadarshi et al., 2022).Another issue is the practice of delayed breastfeeding.Table 1 (quote 1) indicates that women often discard colostrum-the initial thick, sticky, and pale, yellow breast milk-seen as indigestible waste milk, despite its rich nutrients and immune-boosting properties for newborns (Cleveland Clinic, 2022).Tribal women do not breastfeed.Instead, they provide pre-lacteal feeds such as honey, sugar water mixed with traditional herbs, animal milk, and even formula as seen in Table 1 (quote 2).Breastfeeding is further complicated by the high rate of anemia in mothers, with 65% of all tribal women aged 15-49 having anemia, resulting in insufficient breast milk production (The Expert Committee on Tribal Health, 2023).There is a notable lack of breastfeeding among tribal women, which significantly compromises their nutrition and contributes to poor survival rates for newborn.

Community Level
Limited Access to Nutritional Diet and Healthcare Services: Due to poverty and resource scarcity, Madia-Gond children often face malnourishment from insufficient nutritious food.Only 4.5% of Madia-Gond children aged 6-23 months receive an adequate diet, manifesting in 35.4% of children being underweight (National Family Healthy Survey-5 (NFHS-5), 2020).The lack of nutritious food also causes developmental delays and impairments in cognitive functions, with the under-5 stunting rate in the rural Gadchiroli district being 35.7% (NFHS-5, 2020).Proper nutrition and early childhood development activities are crucial for a child's well-being and health.However, postnatal services and nutritional support from the public health department struggle to reach tribal children due to insurgency and challenging terrain.Table 1 (quotes 3 and 4) depicts the lack of nutritious food available for Madia-Gond children.

Limited Access to Education:
In Bhamaragadh, the literacy rate is 46.59%, with female literacy even lower at 19.25% (Government of India, 2011).Older girls frequently care for younger siblings and are married off early due to a lack of education.This educational gap in the tribal community limits knowledge on family planning and modern health, making Madia-Gond children prone to health issues and outdated practices.Table 1 (quotes 5 and 6) describes how children are often kept at home and away from school, especially young girls, who end up participating in household activities.

The Adolescent Experience of Madia-Gond Girls
With multiple influencing factors at socio-cultural and community levels, puberty to late adolescence is a vulnerable time for Madia-Gond girls' physical and reproductive health.

Socio-Cultural Level
Restrictive Cultural Practices during Menstruation Increasing the Risk for Infection: In Madia-Gond culture, girls and women are isolated in small "Kurumaghar" (Menstrual Huts) during menstruation, which are cramped and can be dangerous, especially in the rainy season due to threats like snake bites.Many women, despite disliking these traditions, are compelled to follow them, affecting their reproductive health, and increasing their vulnerability to infections, as highlighted by the dangers outlined in Table 1 (quotes 7  and 8).
Teenage Pregnancies and Early Marriages: Madia-Gonds have a permissive culture regarding partner selection.Upon puberty, tribe members can freely form premarital relationships.Girls and boys socialize and form relationships, often at community centers during "Rela" cultural events, held 3-4 times a year at "Pandum" festivals.Here, they dance together, and boys' express interest by offering girls Kharra, a scented tobacco.As shown in Table 1 (quote 9), couples formed during the Rela night often spend the next few days away from the village.Table 1 (quote 10) depicts that in the Madia-Gond culture, a relationship is deemed genuine when a girl becomes pregnant from it.Traditional practices encourage pregnancy in young girls to solidify future relationships, even if this poses danger to the girl.A lack of sexual literacy in tribal adolescents and physical health often results in teenage pregnancies with adverse health outcomes.The World Health Organization (WHO) indicates that teenage pregnancies contribute to higher rates of low-birth-weight babies, still births, miscarriages, and neonatal mortality (WHO, 2023).Madia-Gond tribal girls often begin childbearing in their early teens, with the first pregnancy sometimes occurring by age 15.Marriage age is not fixed, and many have multiple pregnancies before turning 20.

Cultural Barriers related to Family Planning, Abortion Restrictions, and Access to
Care during Pregnancy: In the Madia-Gond community, unwed pregnant girls typically choose home births due to fears of mistreatment at healthcare centers.Cultural norms prevent tribal women from considering abortion, viewing it as a sin (Table 1, quote 11).So, family planning methods are not adopted or known, leading women to accept all pregnancies, even if they are dangerous to the mother.Some women even resort to using tablets from informal practitioners or traditional herbs secretly to abort, leading to potential dangers like severe blood loss and infections due to incomplete abortions that could be fatal.Due to a lack of knowledge about postpartum care and home-based neonatal care practices, young teenage mothers are vulnerable to health risks associated with handling pregnancy, delivery, and related complications on their own.As a result, there is a pressing need for better sexual education and healthcare support within the Madia-Gond community to improve the health outcomes of young mothers and their children.

Impact of Traditional Practices on MCH:
In Madia-Gond culture, the consumption of tobacco and alcohol is deeply ingrained in festive and marriage celebrations, and women are not exempt from these practices.Table 1 (quotes 12 and 13) exemplifies the role of tobacco in the lives of Madia-Gond women.Tobacco serves as a means of relaxation during tasks like paddy cultivation firewood transportation, leading In Gadchiroli, 26.5% of women above 15 consume tobacco throughout their lifetime (NFHS-5, 2020).This leads to children being exposed to these harmful substances at a very young age.Prenatal exposure to smoking and alcohol has been linked to sudden infant death syndrome, birth defects, brain damage, and low birth weight (Dodge, 2019).These harmful substances can haveto adverse effects on maternal health, as well as on the health and development of the unborn child.The use of tobacco continues during pregnancy and in the post-delivery period, posing significant risks to both the mother and the baby.
Outdated birthing practices also pose risks to the mother and child.Traditionally, home deliveries in these communities are conducted by untrained birth attendants known as "dais."A tribal mother describes in Table 1 (quotes 14 and 15) how dais deliver babies using bare hands, cut the umbilical cord with unsterile blades, and use threads or long hairs as cord clamps.The belief in using ash from burnt leaves or dried cow dung for cord healing reinforces age-old practices.Yet, these methods pose post-delivery infection risks to both newborns and mothers, as weak and premature babies are highly vulnerable to infections such as pneumonia, diarrhea, and sepsis (University of California San Francisco Health, 2021).In the community, new mothers receive guidance from older women who have perpetuated traditional practices for generations.These older women firmly believe in the effectiveness of "pujaris" or traditional healers.As shown by Table 1 (quote 16), seeking treatment from pujaris does not involve monetary expenses or the physical and mental stress of navigating multiple health facilities.Due to their low cost and quick response in emergencies, "pujaris" are the preferred choice for seeking treatment for any kind of illness.One tribal member in Table 1 (quote 17) states that pujaris are often utilized simply due to ease of access, not expertise.While some traditional practices prove beneficial, most are not effective.As a result, many tribal people suffer without seeking proper medical care from either pujaris or health facilities.Local health staff hold a negative perception of the community's preference for healthcare services from pujaris, believing they lack the knowledge and resources to make informed healthcare decisions.Table 1 (quote 18) illustrates the experiences healthcare workers have with tribal members preferring pujaris to allopathic medicine.

Community Level
Experiences with Government's Schemes and Programs: The implementation of government schemes and programs in tribal areas is challenging because of logistic and operational challenges in remote villages.The Janani Suraksha Yojana (JSY), a cash incentive scheme, is designed to reduce maternal and infant mortalities by encouraging institutional deliveries and care via cash at delivery (Gupta e al., 2012).Table 1 (quotes 19 and 20) shows that tribal women face challenges accessing entitlements even when choosing institutional deliveries.Many also lack bank accounts, making them ineligible for JSY funds.
Limited Access to Healthcare Facilities and Transportation Barriers: Tribal women view managing numerous pregnancies and childrearing as routine.Amid financial strains, cultural barriers, and limited health awareness during pregnancy, self-care often becomes secondary, making tribal women high-risk mothers.Antenatal care (ANC) visits are essential for pregnant women's safety, diagnosing high-risk conditions like pre-eclampsia and severe anemia.Tribal women underutilize these services, leading to increased health risks.Madia-Gond women struggle with healthcare access due to limited facilities and remote locations.In emergencies, they seek nearby health centers but often find them inaccessible or understaffed.Deliveries typically happen at Primary Healthcare Centers (PHCs) or rural hospitals, which can be up to 40 km away, with distance exacerbating complications.Inefficiency in diagnosing and treating high-risk pregnancies leads tribal women and families down a dangerous path, even resulting in death in the case presented in Table 1 (quote 22).Table 1 (quote 21) explains that the situation worsens during the rainy season when floods block roads and isolate villages, further endangering the chance of survival.
Adequate care and awareness during the antenatal phase significantly improve pregnancy outcomes.In our study, all respondents registered at ANC clinics, but few knew their last menstrual period or estimated delivery date, with only 10% of tribal women fully utilizing ANC services (Dasra, 2016).Women also faced challenges in complying with the minimum four essential ANC visits due to their distance from sub-centers.Difficult terrain and insurgency described in Table 1 (quote 23) prevented health department personnel from reaching pregnant women, leading to no provision of services.The absence of ultrasound services in local health centers compounds access issues.Splitting ANC and sonography appointments requires women to make repeated visits, leading to lost time and wages from household tasks.This deters tribal women from using ANC and sonography services.Table 1 (quote 24 and 25) shows how pregnant tribal women prefer to travel long distances, often by foot, bicycle, or motorcycle, to access better food and health services at NGO hospitals.Table 1 (quote 26 and 27) highlights the transportation challenges and perilous routes to the hospital and back home.

Inadequate Nutritional Support by Government Facilities:
The expected nutritional support for the undernourished women at government facilities does not work as efficiently as needed.Women (Table 1, quote 28) noted their negative experience with the government healthcare worker not providing promised food to the tribal people, leaving young mothers in a position where they are unable to provide nutritious meals to their family.Many tribal villages also lack government-supported rural childcare centers.Table 1 (quote 29) shows how tribal women are forced to walk 4-5 kilometers to access minimally nutritious meals of rice, lentils, vegetables, and eggs.
Healthcare Providers' Behaviors and Attitudes: Community healthcare workers (CHWs) face challenges in promoting health due to the behavior of other healthcare providers.Table 1 (quote 30) captures a CHW's negative experience with a local tribal doctor, worsened by the poorly maintained facility.The unwelcoming attitudes of health professionals, as shown in Table 1 (quotes 31-34), hinder women's access to care.The absence or inefficiency of health staff leads to multiple referrals, wasting time and resources, especially in emergencies.Such experiences demotivate tribal women from seeking public health services.

Double Burden of Household and Labor Work During Pregnancy:
Pregnant women shoulder a double burden of household work and labor alongside their husbands or families, leading to simple yet difficult lives.Table 1 (quote 35) depicts the strenuous labor that pregnant tribal women endure.This additional workload adds risks to women's lives when they are pregnant.In this study, a significant number of women are homemakers, yet they carry out strenuous work both at home and in the workplace for little pay.Table 1 (quotes 36-38) describes how women annually partake in farming, fetch water from distant sources, and gather forest products like Tendu leaves.Despite the low earnings, this work is vital for household survival, requiring even pregnant or lactating mothers to contribute.The demanding and grueling lifestyle takes a toll on women's physical health, although they gradually adapt to the lifestyle over the years.From one account in Table 1 (quote 39), a CHW describes the life-threatening situations Madia-Gond mothers face as they labor through their pregnancy.Such a strenuous schedule significantly increases the likelihood of poor health outcomes, including preterm births, low birth weight babies, and fatalities (Centers for Disease Control and Prevention (CDC), 2023).

Access to Inadequate Nutrition During Pregnancy and Post-Partum Period:
Despite their strenuous work, Madia-Gond women's nutrition is inadequate in quality and quantity.They primarily consume food with little nutrition like rice, diluted lentils, and occasionally wild vegetables and meat.Table 1 (quote 40) highlights how poverty and scarce food availability often mean women eat less.Cultural dietary restrictions during pregnancy further limit their intake, barring certain vegetables, fruits, and meats.Breastfeeding mothers traditionally follow a postpartum diet of soft rice with salt and occasionally red chili powder for days to months (quote 41).The belief is that white rice helps stimulate more breast milk production and is easily digestible.However, this cultural practice contradicts various maternal and child health guidelines, which recommend providing mothers with a nutritious diet in sufficient quantities to aid post-delivery recovery (Quam and Anderson-Villaluz, 2021).Maternal malnutrition significantly impacts the health of newborns, especially low birth weight babies.Ideally, a breastfeeding mother should eat frequently and consume larger portions to support the energy demands of breastfeeding (Quam and Anderson-Villaluz, 2021).However, these women adhere to traditional rules and restrictions passed down through generations in their community.Many women state their shared experience (Table 1, quote 42) in which family members push traditional practices at the expense of the health of themselves and their children.Furthermore, some women even experience such lack of nutrition in the post-partum period, contributing to health issues like anemia in the mother and malnutrition in infants, as explained by Table 1 (quotes 43 and 44).

Discussion
This study examined factors associated with maternal and child health problems in tribal areas in India.The study utilized qualitative methodologies to analyze the diverse interactions between well established Government healthcare systems and tribal mothers' and children's access to care.Applying a life course framework (Jones et al., 2019) as the analytical lens, the study revealed a trajectory of mortality and morbidity risks, from birth to adulthood.The challenges that tribal women and children face are intricately linked to the geographical isolation of tribal villages, the prevailing state of poverty, the dependence on traditional healing practices, insufficient nutrition, and the demanding nature of both domestic and occupational work.The findings emphasize the pressing requirement for holistic interventions aimed at tackling these intricate challenges, with the goal of improving the health and well-being of tribal women and children in India.

Factors Related to Health Risks in Adolescence and Adulthood
Women described, through lived and shared experiences, the trajectory of their health across the different stages of life, commencing from childhood and adolescence.These narratives provided insights into factors that place tribal women at risk for poor health outcomes.For instance, a lack of sexual literacy in tribal adolescents often results in teenage pregnancies with adverse health outcomes.The World Health Organization (WHO) indicates that teenage pregnancies contribute to higher rates of low-birth-weight babies, still births, miscarriages, and neonatal mortality (WHO, 2023).Early marriages and traditional practices encouraging pregnancy in adolescence, placed Madia-Gond girls at risk for adverse pregnancy outcomes.Further, the practices of tobacco and alcohol consumption at a very young age posed a risk to young mothers and their children.In Gadchiroli, 26.5% of women above 15 consume tobacco throughout their lifetime (NFHS-5, 2020).This leads to children being exposed to these harmful substances at a very young age.Prenatal exposure to smoking and alcohol has been linked to sudden infant death syndrome, birth defects, brain damage, and low birth weight (Dodge, 2019).Moreover, the mortality and morbidity risks among the tribes were also driven by the challenges and barriers they encountered in accessing healthcare services.In this study, participants shared that insufficient economic means, impoverished conditions, transportation barriers and an adherence to traditional healthcare practices created obstacles in obtaining optimum maternal and child healthcare services.This is supported by prior research that found that only 10% of tribal women fully utilized necessary ANC services (Dasra, 2016).Additionally, the lack of educational opportunities detrimentally impacted health and well-being of Madia-Gond women, stemming from their restricted knowledge of available healthcare services.This problem is evident in Bhamaragadh, where literacy rates are alarmingly low at 46.59%, and even more so for women, at a mere 19.25% (Government of India, 2011).A similar pattern is observed in Gadchiroli, where a mere 32.7% of women are informed about family planning services, resulting in a substantial deficit in education about safe family planning techniques (NFHS-5, 2020).
Poverty among the tribes also results in insufficient nourishment for women in prenatal and postpartum period.This often presents itself as anemia, a condition suffered by 65 % of tribal women (The Expert Committee on Tribal Health, 2023).The insufficiency of nourishment is further intensified by the obligation for tribal women to engage in labor to sustain the household.The combination of anemia and strenuous labor places added strain on both the expectant mother and the developing fetus (Center for Disease Control and Prevention (CDC), 2023).Further, maternal malnutrition significantly impacts the health of newborns, especially low birth weight babies.Ideally, a breastfeeding mother should eat frequently and consume larger portions to support the energy demands of breastfeeding (Quam and Anderson-Villaluz, 2021).However, these women adhere to traditional rules and restrictions passed down through generations in their community.In a study in North India, maternal mortality rate in the tribal region was primarily attributed to anemia worsened by unhygienic labor practices and incorrect guidance from traditional healers (Chauhan et al., 2012).Traditional healing methods increase the risk of post-delivery infections for both mothers and newborns.Newborns, particularly those who are weak and premature, are highly susceptible to infections like pneumonia, diarrhea, and sepsis (University of California San Francisco Health, 2021).Research undertaken among tribal women in Odisha, India revealed that merely 6% of the surveyed tribals solely opted for allopathic medical treatments (Mahapatro et al., 2000).Instead, 49% of the participants leaned towards traditional remedies, often administered by local unlicensed practitioners (Mahapatro et al., 2000).Adherence to traditional remedies that lack scientific evidence increases mortality and morbidity risks.A study conducted in Bastar, Chhattisgarh, a locale where 70% of the populace comprises tribal communities, revealed a stark contrast in maternal mortality rates.Among tribal women, the maternal mortality rate stood at 100%, while among non-tribal women, it was reported to be 0% (Chauhan et al., 2012).Further, geographical isolation, insufficient transportation framework, and great distances to healthcare establishments present noteworthy difficulties for tribal populations in their pursuit of maternal and child healthcare services.

Factors Related to Health Risks in Childhood
The glaring disparities in child health outcomes among tribal populations, particularly concerning child mortality rates, are associated with factors such as traditional childcare practices, limited access to nutritional diet and healthcare services and limited access to education.The Infant Mortality Rate (IMR) among tribal children surpasses the national average of India by 30% (Dasra, 2016).Bhamaragadh's neonatal mortality is high, accounting for 12.4% of Maharashtra's total neonatal deaths (Saunik et al., 2017).Furthermore, a child born into a tribal family has a 19% higher chance of dying in the neonatal period and 45% higher risk of dying in the post-neonatal period compared with children of other social groups (Narain, 2019).These alarming statistics underscore the critical need to address the underlying factors contributing to such disparities and to devise strategies that specifically cater to the healthcare needs of tribal children.Madia-Gond children, as well as their counterparts from other tribal communities, confront health challenges marked by inadequate nutrition, substandard living conditions, heightened vulnerability to infectious diseases and complications from outdated traditional practices.The scarcity of essential nutrients, often attributed to economic constraints and limited access to nutritious food sources, contributes to stunted growth and compromised immune systems among these children.For instance, in a study in India, a significant percentage of tribal children, approximately 53%, suffered stunted growth, while 29% experienced severe stunting, and 55% were underweight (Nikitin et al., 2010).Moreover, only 4.5% of tribal children aged 6-23 months receive an adequate diet, manifesting in 35.4% of children being underweight (National Family Healthy Survey-5 [NFHS-5], 2020).The lack of nutritious food also causes developmental delays and impairments in cognitive functions, with the under-5 stunting rate in the rural Gadchiroli district being 35.7% (NFHS-5, 2020).This nutritional deficiency is exacerbated by substandard living conditions, characterized by overcrowded and unsanitary environments, which create a conducive breeding ground for infectious diseases.Furthermore, the persistence of outdated traditional practices, rooted in tribal cultures, expose these children to preventable health risks.Practices such as unhygienic birthing methods and reliance on traditional healers can lead to complications during childbirth and untreated infections, heightening the vulnerability of tribal children to serious health issues (Kumar et al., 2020).Addressing these interrelated challenges requires comprehensive interventions that encompass improved nutritional support, enhanced living conditions, and culturally sensitive healthcare practices tailored to the unique needs of tribal communities and their children.

Access to Healthcare Services
To foster change and improve maternal and child health outcomes in Bhamaragadh and other tribal regions, a multi-faceted approach is required.Policy interventions should focus on improving healthcare infrastructure and services in the region.There is need for comprehensive maternal care initiatives, encompassing strengthened antenatal and postnatal care and nutritional guidance and access among the tribes (Kumar et al., 2020).Increasing the number of trained healthcare professionals, including skilled birth attendants, and strengthening referral systems to provide timely and quality emergency obstetric care can significantly reduce maternal mortality rates among tribal populations.Redesigning parts of the public healthcare sector to include monetary and nonmonetary incentives can encourage healthcare workers and physicians to work in remote tribal areas (Kumar et al., 2020).
Nutrition interventions are also crucial to combat malnutrition in these tribal communities.The implementation of government schemes such as the Integrated Child Development Services can play a pivotal role in providing nutritious food, immunization, and growth monitoring for children (Sachdev & Dasgupta, 2001).Additionally, promoting breastfeeding, educating mothers about appropriate childbearing practices, and encouraging family planning are vital steps in preventing maternal and child mortality (Agampodi et al., 2021).In essence, conducting extensive research on the healthcare disparities experienced by tribal communities holds the potential to wield significant influence on policy formulation and funding allocation.Such research insights can pave the way for targeted improvements in healthcare infrastructure, thereby facilitating increased accessibility to essential medical personnel, nutritious sustenance, and educational resources in remote tribal-populated regions.

Health Risks for Madia-Gond Women and Children
Figure 1.

Table 1 .
Example Quotes from participants