Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 28 (2) March 2018www.eubios.info
ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)
Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2018 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

page
Editorial: Ethics, knowledge and body function37- Darryl Macer
The ethical impacts of routine use of digital eyeglasseson the doctor-patient interaction
38- Sody A Naimer
Palatal rugae pattern identification to determine family
lineage in Minangkabau, West Sumatera, Indonesia 42- Nila Kasuma, M.Biomed, Dewi Elianora, Aida Fitriana,
M.Biomed, Fildzah Nurul Fajrin, Haria Fitri
Female genital cutting: a philosophical exposition 45- Joseph Nkang Ogar, Bassey Samuel Akpan
Bases of Early Marriage & Consequences on the Wellbeing of Mother and Child in Jhirubas, Palpa, Nepal 51- Bikash Thapa & Darryl Macer
Prevalence of Oral and Dental Diseases and Oral Hygiene
Practices among Illicit Drug Abusers
65- Md. Anower Hussain Mian, Kazi Md. Sakib Hossain,
Nasrin Akhter & Darryl Macer
ABA Renewal and EJAIB Subscription
81

Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President,
American University of Sovereign Nations (AUSN)
Email: darryl@eubios.info
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Registered address of EJAIB: P.O. Box 16 329,
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Editorial: Ethics, knowledge andbody functions
This is the issue of EJAIB is extended to 44 pages
to include several lengthy papers that present
aspects of biomedical ethics in areas which are notoften, if ever, explored. We can ask questions about
the application of the knowledge of our body, andhow this may be and should or should not be
explored in new ways.
The ethical impacts of routine use of digital
eyeglasses on the doctor-patient interaction are
explored by Sody Naimer. As our lifes are driven to
render most of us some form of cyborg (even by
wearing basic sight or hearing aids), we arepresented with technology that can provide us new
information about our daily interactions. The data
could be gathered to better monitor what we do –but do we all consent to such data gathering? This
comes at a time when there is concern over the datacollection of social media platforms.
Two papers explore dentistry. Kasuma et al.
show how palatal rugae pattern identification has
been used determine family lineage in
Minangkabau, West Sumatera, Indonesia. This also
raises questions of privacy versus familial solidarity.
Despite legal bans, the practice of female genital
cutting continues, and some of the reasons for thiscontinued abuse of often young women and girls
are explored by Joseph Nkang Ogar and Bassey
Samuel Akpan. Sexuality and culture are themes incommon with the analysis of interviews describedby Bikash Thapa in his Masters ‘s thesis research on
the bases of Early Marriage and Consequences on
the Well-being of Mother and Child in Jhirubas,
Palpa, Nepal Despite the many health problems,
early marriage is still common in many countries.
Md. Anower Hussain Mian et al. conducted adental and oral hygiene survey among Illicit Drug
Abusers in Dhaka, and we can see that this is aneglected group who are also neglecting their teeth.
. - Darryl Macer

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Eubios Journal of Asian and International Bioethics 28 (March 2018)

The ethical impacts of routine useof digital eyeglasses on the
doctor-patient interaction- Sody A Naimer, M.D.
Department of Family Medicine, Siaal Research Center
for Family Medicine and Primary Care, Division ofCommunity Health, Faculty of Health Sciences, BenGurion University of the Negev, Beer-Sheva, Israel
Email: sodyna@clalit.org.il

Abstract
In parallel to society at large, the past three decades
have seen a dramatic rise in adoption of computer
technology in the medical field. As rival commercial
enterprises compete in developing the most ideal"digital eyeglass", the time is ripe to prepare an
ethical approach to this phenomenon and its impact
on the doctor-patient consultation. Wearing a
multimedia system will carry with it bothadvantages
andinherent
disadvantages.
Particularly worrisome issues lie within the domain
of autonomy, confidentiality, and spontaneity. In
this paper, the ethical questions raised by the use ofdigital eyeglasses in the course of the medical officevisit are addressed. The choice of use by thephysician and the patient are discussed separately.
There is a need for guidelines of an appropriate
approach by medical staff and their patients in
preparation for this novel phenomenon.
Introduction"Digital eyeglasses" (DEG) are already here, andnow is the turning point for preparation before its
technological finesse becomes a social phenomenon
creeping under the door into the doctor's office.
What patients seek is personal attention,compassion, understanding, and care until thepresenting problem is resolved. The care provider's
prime concern is to provide the patient with
undivided attention, recognise the essence of the
problem, employ the necessary resources to deliver
the most favourable resolution, and feel satisfied
that the individual received correct care. However,
the environment in which this interaction isconducted has changed.
With growing restraints of time and theescalating burden of tasks, the physician must
become more concise and problem oriented. Abalance is needed to minimize the discrepancy ofcatering to the patient's needs and feelings,
conferring an immense influence on patient's
health behaviours, and limited resources to fulfil
these goals. Adoption of any one of a number ofsolutions is welcome to bridge these gaps. We haverecently resorted to incorporating advanced
technology into primary care on a national level.

However, we often pay a high price for theadvantages of implementation of a further
computerized environment. Electronic medical
record documentation is an example where many
aspects of patient care have been sacrificed in orderto propagate better storage and more convenient
access to the medical database (1-3). We cope withthe consequences that our digitalized society has on
us. This transition bears considerable impact on the
doctor-patient dynamic. It seems the end of thisjourney is yet to be determined.
The revolutionary hand-held cellular telephone
has evolved into a smartphone that is a multifunction multimedia appliance with all thecapabilities of recording and documenting audio
and visual stills or motion pictures in perfect colourforreproducibility
invariousforms.
Computerization has become ubiquitous andencompasses almost all branches of clinicalmedicine. From ordering tests, to sifting throughresearch results, memory storage, data comparison,records of previous consultations, diagnostic
modalities, cautionary signs of hypersensitivities,
and information mining all the way totranscontinental robotic surgical procedures. In
this paper we would like to delve into a single
aspect of this development, namely the inseparable
conformation of the gadgetry into part of theindividual self. We may now cope with the newphenomenon of DEG, or "augmented reality", ofwhich the most advanced device is Google Glass(Google Inc., Mountain View, CA).
What is Google Glass?
Google Glass is a wearable android-powered
computer coupled with an optical head-mounted
display (OHMD). Information is displayed in asmartphone-like hands-free format onto a prismlike rectangle at a corner of one’s field of visionutilizing innovative liquid crystal on a silicon fieldsequential colour system. The technology enables
still or video photography with a camera built into
spectacle frames. Communication is possible with
the Internet via voice commands, head tilts, and atouchpad on the side. It can run special applications,
make video calls, and facilitate hands-free web
searching. It is planned to open endless options ofdesign to wirelessly accommodate personal
medical documents that have been archived or datafrom transmitted monitors such as blood glucose
measurements (4), from the patient's perspective
and face recognition, to hazard warnings of druginteractions from the perspective of the physician.
Google started selling a prototype of Google Glassto qualified "Glass Explorers" in the US on April 15,
2013, for a limited period for $1,500. Currently off
the market, the company continues its efforts toperfect the device into a more feasible applianceEubios Journal of Asian and International Bioethics 28 (March 2018)that corrects technical problems that arose such as
short battery life and inconsistent functioning. The
assumption is that just as it has evolved from a
3,600 g prototype in mid-2011 to the 2013 modelthat is lighter than the average pair of sunglasses,
soon it may turn into a custom artefact as popular
as the smartphone. If so, it should be in order todelve into morally setting rules and limitations
before becoming overwhelmed by a newphenomenon reaching our doorstep before
adequate preparation. In this work we concentrateon the impact it may have on primary careconsultations.

Advantages of DEG and its utilization invarious medical scenarios
Increasing fields of medicine are utilizing thisdevice as a wearable and special-purpose device forvarious purposes. A number of proof-of-concept
projects and studies using DEG have been
undertaken in the medical field. Its applications
include remote collaboration between doctors,
heads-up viewing of vital signs, medications, andlab reports, as well as live streaming of operations
to medical students (5). A recent reportdemonstrates its advantages in the care of chronic
wounds (6).
Wearable augmented reality systems have also
been demonstrated in a range of clinical application
areas such as image-guided surgery, pre-operative
imaging training, health-related behaviour change,
and clinical education (7). Studies have examined
the use of DEG systems for both in-patient andremote medical procedures (8).
Problems arising with DEG technology
The most recent development deserving
fundamental scrutiny arrived with the current
progress in developing a similar device with thecapacity to activate any of its components hands
free. The fearful aspect of this change is that if
accepted, and if applied without restraint, thesedevices can potentially dominate human attire to an
extent that may lead to universal violation ofprivacy. Worn recording electronics carry withthem advantages as well as disadvantages

39

regarding both the professional aspiring to provide
the most updated care as quickly as possible, and to
the patient expecting to receive the highest qualityof treatment (9). Along with the staging of thisdevice, safety issues such as driving while donningsuch a device raise many concerns (10). A large
professional team invited by the Office of thePrivacy Commissioner of Canada met to judge theimplications of such an item on privacy issues andimmediately demanded resolution by the executive
director of the marketers.
Issues to be addressed
Transformation into a world where any movement
or voice can be recorded for personal or other use
raises indeterminable social issues as it challenges
human behavioural ethics in general. The medical
field is only one aspect of the technical cyberuniverse in the making. For example, two very
important aspects that confound this transition are,firstly, the actual process of documentation that
may become completely undetectable, since
without a functioning blinking indicator activatedwhen recording is in progress, the party facing thelens or microphone remains ignorant of thisongoing process. The traditional vocal commands
or fingertip tap of the frame arm needed to activate
or deactivate any of the device’s functions are now
replaced by a mere head tilt or a programmed winksequence. Secondly, as use of the computer
spectacles advances to become the norm, a regularhuman attire may be sought as opposed to current
instances of asking for permission to carry acellular telephone into a visit and place it on thedesk or raise it to a position to facilitate
photography; instead, the demand will be toremove the device in order to create the desired
atmosphere.
Both the upside and downside should beconsidered in order to determine the desired extent
of tolerance towards device use in order to reap the
benefits that may be derived from this newtechnology. The questions we would like to raise
include social and ethical issues, for example, thesurreptitious collection of information about otherindividuals and its possible use by a third party for
quality care or medical education purposes. Is there
such a thing as a general permissive attitude in an
era where all is exposed and information
accessibility so simple? Yesterday’s gimmick
becomes today's normative behaviour. Will we all
become victims of privacy and intimacy invasion ona regular basis? From Google Earth to publicdomain camera surveillance practically every
motion and instant recording will prevail. Suddenly
our subconscious becomes aware of the fact that an
intruder has become part and parcel of thephysician-patient encounter, brought in by either

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Eubios Journal of Asian and International Bioethics 28 (March 2018)

party or both. This can result in an obstacle thatwill shed new meaning to the famous nursery
rhyme written long before the computer chip wasdevised:"I do not like thee, Dr. Fell; The reason why I
cannot tell; But this I know, and know full well,
I do not like thee, Doctor Fell!" (Mother Goose).
Despite an abundance of accounts of thereinforcement of care with DEG, authors have notcontributed a discussion to the literature on theneed to define their uses in keeping with an ethics
code or set of values. An overt rejection of therecent introduction of mobile devices into healthfacilities on the basis of fears of breach of privacy
has failed, as an anonymous hospital administrator
explained:"Acceptance of personal mobile devices by thehospitals was predictable, as there are three
things in life that are inevitable: death, taxes, andtechnology. Technology is trying to eliminate thefirst two items on the list."Thus, we must improve our vigilance by expecting
such innovative technology as imminent andprepare ourselves accordingly.
Ethical considerations
Despite efforts to improve patient care in theprocess, we must safeguard ourselves into minding
not to breach ethical principles. Fundamental
principles in need of attention that immediately
rise when considering this encounter relate to theatmosphere and confidentiality of the visit.
1. "Effective communication is critical to a secure
patient–physician relationship. The physician has aduty to promote patient understanding and should
be aware of any barriers" (11). Are we certain thatthe introduction of DEG does not impede theircommunication?
2. "Confidentiality is a matter of respecting theprivacy of patients, encouraging them to seek
medical care and discuss their problems candidly …"(11). Is the use of a multimedia recording device inthe centre of the communication "space" not athreat to that Holy Grail?
Systematic analysis of the benefits versus the
drawbacks of a new practice of DEG adoption will
only be possible if we analyse separately its use byeach of the involved parties and then weighbenefits versus risks in each category.
Physicians’ use of digital eyeglasses in thecourse of medical consultation
Physician-related pros: The motivation to use thistechnology seems obvious. To begin with, the facialrecognition application can prevent the discomfort
of forgetting the patent's identity. Misguided
documentation in the wrong file can be overcome
and a more personal atmosphere can prevail when

the patient's name is used. Documentation is easierfor future reference and multimedia options
facilitate following up on dynamic conditions where
detailed alterations need comparison. This will not
only improve patient care but it can safeguard
against allegations of misconduct as risk
management is fortified by proof of circumstancesthat led to decisions taken. In addition to theadvantages of a standard computer with Internet
access to the patient's previous material andupdated medical literature, scientific therapeutic
guidelines as well as the health plan's directives areeasily accessed. In addition, real time specialist or
even peer remote consultation is possible. Rather
than describing findings, this way the signs ofdisease are exposed and all audio and visual cues
can be picked up by the contacted physician andrecommendations
canbeimmediately
implemented.
Voice activated commands can save time.
Information can be accessed or perceived in thecourse of hands-on care such as removing dressings,
preparing equipment, or examination. In freemoments during a visit various means can be
employed in order to enhance productivity, similar
to the evidence of increased work productivity inthe atmosphere of pleasant music (12).
Patient-related pros: Primarily, a computer
screen already exists in many systems where theelectronic medical record has been incorporated
into practice. Decreasing the size of this screen andchanging the attention to body language as if thephysician is looking directly at the patient
throughout the encounter is a clear advantage.
Surely the patient prefers to sense that alltechnological progress is recruited to ensure thatthe best care is delivered. Patients stand to benefit
from the fact that another perspective is called in toreview their case, which will encourage utilizing theconsultation potential of this system.
Physician-related cons: The learning curve is as
yet undetermined. Just as with any newly
introduced technology, mastery is time consuming.
Often, use of multi-modalities intended to facilitate
work may become a hindrance itself. Hence, we stilllack the experience of the benefits of this new
option in primary care. Multitasking is actually thecomplete premise of this whole project and noteveryone is suited for such changes. The physician
may personally be distraught by the perception thatthe patient is receiving complete attention while infact the screen demands a significant bulk of it.
Dependence on media may be faulty, missing, or
exhibit malfunction. We are often overly dependent
on electricity and a discharged battery can cause
great inconvenience.
Patient-related cons: During a visit the patient
may actually experience the doctor’s divided

Eubios Journal of Asian and International Bioethics 28 (March 2018)attention. Furthermore, the presence of asuperfluous “visitor” may create a new barrier andinterferewiththediscrete
personalized
atmosphere where all secrecy and privacy isrespected. This new physical medium can impose atechnical impersonal contact between the two
individuals and can pose a sense of threat. Patients
may also fear their caregiver’s distraction fromtraditional cues, body language and other obscure
messages. If especially sensitive issues are raised in
the encounter, distrust or fear of reproducing
uncomfortable subjects may lead to conditions
unvaforable to open disturbing topics of major
concern by the patient.
Patients’ use of digital eyeglasses in thecourse of the medical consultation
Physician-related pros: It is always preferable forthe physician to provide a pleasant atmosphere byallowing the patient to dictate the terms andconditions of the visit. As current status stands, thenature and content and depth of the visit are always
guided by the patient’s will. Therefore it may seem
equally legitimate that the terms of the encounterare also patient centred. Language orcommunication barriers may call for theparticipation of an additional family member or
acquaintance who was not available to physicallyescort the patient, in which case it may be in thepatient’s best interest to have an additional party
present to assist in ensuring that the message isconveyed, for the sake of compliance. Instanceswhere instructions are complicated or lengthy will
benefit from a short take-home video for review at
a later time. The two-way transfer of material isfacilitated.
Patient-related pros: The technology may allow
the encounter to be as casual as possible andextend complete liberty to the patient in choosing
dress and behaviour. Some individuals’ esteem isboosted – if they have a tendency to boast, a senseof importance, keeping up with the times – when
they are convinced that gadgetry is a status symbol.
Such a recording tool can enhance a sense of
security of accessing any information required anddocumenting information instantly. For instance,
instructions can be recalled instantly at a later time.
Any distantly located party can immediately join
the consultation at will and assist in communication,clarifying issues or even offering moral support.
Physician-related cons: Again, with the burden oftime constraints outright frustration will result
from suspicion that the patient is not completely
attuned to the physician's explanations andrecommendations, just as antagonism may arise if
while communicating the patient fidgeted withanother electronic device. The physician may fear
recording of any part of the encounter as it may

41

perhaps be used against him in the case of a lawsuit
and thus this will bring about overly careful
unnatural conduct not necessarily to the benefit of
the patient, for instance over-testing or superfluous
medication dispensing.
Patient-related cons: Patients with DEG may offer
a divided attention throughout the visit while
appointments are scarce and their unperturbed
character should be preserved at all costs. The
presence of a superfluous visitor may create a new
barrier and may interfere with the longed-for
discrete personalized atmosphere where secrecy
and privacy are respected. Any technical faults
occurring with device activation or ongoing
function may preoccupy the patient and result inomission of important visit content.
There are possible solutions, for instance anagreement that mutual permission should beobtained before undertaking DEG use during theencounter, just as other institutions invoke policydriven limitations on recording devices. This mustbe personalized towards the care seeker and thesituation. To be applied smoothly, consent should
be willingly sought by both parties.
Despite the fast pace of evolution into a mostly
computerized environment, resolving the mostpushing aspects and the sanctity of the doctor
patient consultation is within our reach. We cansafely assure that with perseverance we may pave
the path to solve communication barriers as withother aspects of the medical consultation (13).
Conclusions
In this paper problems in the use of digital
eyeglasses during the classic doctor's visit are
discussed. A high-tech environment contributes
many benefits to varied fields, and medicine is
obviously no exception. Provisions must be made to
mitigate breach of ethical principles and possible
harm to interpersonal communication, especially of
medical content, before becoming overwhelmed byhazards the new paraphernalia may present.
Suggestions for resolving issues may be obtained bybrainstorming, creating a model, global institutionof social demand for consent and tailoring use
according to situation and subject.
This issue poses a new challenge crossing ourpath on the way to making our world a better place.
Nevertheless, every precaution must be taken to
ensure that this is not at the expense of
jeopardizing the essence of the doctor–patientencounter. With perseverance and joint effort thesegoals seem achievable.
References

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Eubios Journal of Asian and International Bioethics 28 (March 2018)

2. Krist AH. Electronic health record innovations forhealthier patients and happier doctors. Journal of
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Palatal rugae pattern
identification to determine family
lineage in Minangkabau, West
Sumatera, Indonesia- Dr.drg. Nila Kasuma, M.Biomed,
Faculty of Dentistry, Andalas University, Indonesia
nilakasuma10@gmail.com- Dr. drg. Dewi Elianora, Sp KGA,
Faculty of Dentistry, Baiturrahmah University, Indonesia
dewielianora12345@gmail.com- drg. Aida Fitriana, M.Biomed,
Faculty of Dentistry, Andalas University, Indonesia
aidanoferi@gmail.com- drg. Fildzah Nurul Fajrin,
Faculty of Medicine, Andalas University, Indonesia
rin.inoochi@gmail.com- drg. Haria Fitri,
Faculty of Dentistry, Andalas University, Indonesia
hariafitri5@gmail.com

Abstract

Background: This paper discusses palatal rugae
patterns and their contribution in the identificationof individuals and the determination of family
lineage in West Sumatera, Indonesia. Identifying an
individual is very useful for postmortem
examination, for personal, social and legal
purposes. The most common techniques used inthis context are dental records, fingerprint and DNA
comparisons. However, these methods cannot be
used under certain circumstances. But interestingly
palatal rugae patterns are preservable because they
are stable, and impervious to disasters and hostile
conditions and therefore can be used as alternative
human identification techniques. This paper argues
that the study of palatal rugae (rugoscopy) not only
help reveal a person’s identity but also help
determine their family lineage.
Objective: The present study was carried out toascertain whether there are any hereditarypatterns in the palatal rugae patterns of the mother,father, and the offpring in one family.
Method: This is a cross sectional study of 48
samples consisting of 12 families in Luhak Nan
Tigo. The parents and offspring (son or daughter) of
each family were randomly selected. Palatal rugae
impression was recorded using alginate, whilepalatal rugae patterns were noted and recorded.
One Way ANOVA test (SPSS 17) was used forstatistical anaysis.
Result: The study shows that there is a significant
similarity in curved, wavy, and straight rugae
patterns (p> 0.05) as well as in primary, secondary,
and fragmented rugae based on the family tie
between the father, mother, sons and daughters of
the Minangkabau ethnics. Unilateral and circularrugae tests are insignificant (p <0.05).
Conclussion: This is a cross sectional study whose
results are only based on 48 samples consisting of
12 families, therefore further studies are neededwith a larger sample quantity. The results of thisstudy indicate the role of factors in palatal rugae
patterns.
Introduction
In the last few decades, Indonesia has dealt withmore than 400 natural disasters of which floods,
fires, typhoons and landslides are the mostcommon. In addition to this, disasters such as
earthquakes, tsunamis and volcano eruptions also
occur on a yearly basis.1 These natural disasters
have caused the death of tens of thousands ofpeople in West Sumatran, one of the disaster-prone
areas in Indonesia. Sadly however, many of theseEubios Journal of Asian and International Bioethics 28 (March 2018)
victims were not identified due to the lack offinancial or material means to conduct
identification procedures.
In order to issue the death certificate of an
unknown/unidentified deceased person, or for
personal, social and legal reasons, DNA test, retina,
fingerprints and dental characteristics are the mostcommon techniques referred to in forensic science.
However, many of these methods may not be totallyeffective or conclusive.2 Hence the need for the
study of palatal rugae as an alternative method forthe scientific identification of individuals. Palatalrugae can be very useful for the identification of
victims of mass disasters such as earthquakes,
landslides and tsunamis, etc., crime investigations,
ethnic studies, and in the identification of
decomposed and disfigured bodies as a result ofdrowning, burns, and accidents.3
Rugoscopy, cheiloscopy, bite marks, tooth prints,
radiographs, photographic study, and molecularmethods are various methods employed in forensic
odontology. When these methods of identification
are unavailable, however, palatal rugae may beconsidered as an alternative source of information
to facilatate the identification process.2 There areseveral classifiations of palatal rugae. But the mostfrequent used is the classification given by Thomas
and Kotze,2 which classifies Palatal rugaes in three
categories based on their length: Primary rugae(more than 5 mm in length), secondary rugae (3-5mm in length) and fragmented rugae (<2 mm inlength).
The patterns of the rugae are classified into
curved, wavy, straight and circular types. Straightpatterns have a direct course from the point oforigin to their insertion in a straight line. Curved
patterns have a crescent shaped pattern with a mild
curvature. Wavy rugae are serpentine in shape.
Rugae with specific continuous ring typemorphology are classified as circular. Unified
rugaes are united either in their origin or in theirinsertion giving a forked appearance. These are thepatterns involved in this study conducted to assess
the association of palatal rugae patterns amongfamily members of the Minangkabau, a subgroup of
the Deutro Malay ethnic, which consist of Aceh,
Malay, Minahasa, Bugis, Makasar, Sasak, Bali, Java,and Minangkabau.5
Methods
This research was conducted in Luhak Nan Tigo
located at Guguak, Situjuh, and Tanjung Subdistricts in the District of 50 Kota, Tanjung Baru
subdistrict situated at the District of Luhak Tanah
Datar, and in Baso, Banuhampu, and Tanjung Raya
Subdistricts located at the District of Luhak Agam.
The study was conducted from January to June
2017. A total of 489 palatal rugaes were observed

43

in 48 palatal rugae models from 12 families. The
study was conducted with the door to door systemin each subdistrict. Prints of jaws of the
respondents were obtained after the research was
explained to them and informed consent wasprovided. The Commitee of the Research Ethics ofthe Faculty of Medicine, Andalas University, withregard to the protection of human rights andwelfare in medical health research has carefully
reviewed the research protocol with Ethical
Clearance number 073 / KEP / FK2017 on March
2nd 2017.

Figure 1: Delineation of palatal rugae pattern on
dental casts

Maxillary impression was done using irreversiblehydrocolloid alginate. The impressions were castusing dental stone type 3. The jaws were printed
using irreversible hydrocolloid material i.e., alginat.
The result of the jaw printing was cast using dentalstone tipe 3. The maxillary cast analysis was
performed single-blind by two different observers
to get accurate measurements and reliable results,then classified based on Thomas- Kotze and Sunita
Kapali classification method. Observers are dentistsof the Faculty of Dentistry University Andalas who
have good eyesight, understanding and perception.
The same procedure was used in length
measurement and observation of palatal rugae
patterns. The Result Measurement of each observer
was tested using Technical Error of test
Measurement (TEM), intra-observer and interobserver. TEM test was performed on 20 samplesof maxillary cast having primary rugae andsecondary rugae.
Results
This study was conducted to assess the similarity ofpalatal rugae patterns between family members,i.e., father, mother, sons and daughters of the
Minangkabau ethnic. A total of 489 palatal rugaes
were observed in 48 palatal rugae models from 12
families. One Way Anova test results of curved,
wavy, and straight rugaes are p> 0.05, whichindicates that there is a significant similarity in the
shape patterns. The results of the unilateral and44

Eubios Journal of Asian and International Bioethics 28 (March 2018)

circular rugae form test are p <0.05, whichindicates there is an insignificant similarity in thepatterns of uniform and circular form. The resultsof the primary, secondary, and fragmented rugae
test are p> 0.05, indicating a significant similarity inthe palatal rugae patterns based on the family tie
between the father, mother, sons and daughters of a
Minangkabau family. The average number of palatalrugae and p value in this study are as follows:
Tabel 1: Average Amount of Palatal Rugae
Rugae Pattern Mothe Fathe
Son
Daugh
r
r
ter
Curve
2.92±1 4.08±1 3.08±1 2.92±1
.67
.92
.78
.37
Wavy
2.92±1 3.42±1 4.05±2 4.75±2
.67
.92
.19
.52
Sha Straight 2.00±1 1.75±1 2.50±1 1.83±1
pe
.70
.28
.44
.11
Unified 1.50±1 0.50±0 1.08±0 0.50±0
.16
.90
.99
.67
Circular000.08±0 0.42±0.28.66
Primary 7.25±1 7.83±1 8.33±1 8.17±1
.81
.26
.07
.26
Size Second 1.67±1 1.83±1 2.17±1 1.75±1
ary
.37
.40
.74
.13
Fragme 0.42±0 0.08±0 0.75±1 0.05±0
nted
.66
.66
.71
.90

P
0.
28
0.
11
0.
56
0.
03
0.
02
0.
24
0.
83
0.
47

Discussion
Sumatra is the second biggest island in Indonesia
after Java Island, and the sixth biggest in the world.
Its Western coast, known as Sumatera Barat (WestSumatera), is home to the Minangkabau people
whose culture (budaya Minang) is handed down inregions such as Luhak Nan Tigo –Luhak Agam,
Luihak Tanah Datar and Luhak Lima Puluh.6 This is
the reason why the research was conduted at theselocations.
Palatal rugaes are irregular, asymmetric ridges ofmucous membrane of the incisive papilla and theanterior part of the median palatal raphe, locatedbehind the maxillary central incisor teeth.7
Harrison Allen was the first to suggest the use ofpalatal rugae as a method of personal identificationin 1889. But it was not until 1932 that the term
“palatal rugoscopy” was brought up by Trobo
Hermosa, a Spanish investigator.2 Palatal rugae
normally begin to form towards the third month ofprenatal life. Palatal rugae patterns are unique. The
uniqueness of palatal rugae patterns may facilitate
their use in postmortem identification. This is dueto the fact that palatal rugae is stable and can resist
postmortem decomposition changes for up to 7
days after death and can withstand great thermal
insults like third degree burns.
Because palatal rugae is protected by the tongue,
dentition, and cheeks, it can resist other forms of

massive trauma.8 The identification of a person
through DNA examination has limitations such as
contamination and high cost, while the use ofpalatal rugae can provide ideal parameters becauseof its uniqueness, stability, resistance, and simple
and inexpensive methods. The potential use ofpalatal rugae in forensic identification has
advantages because it is sufficiently able todiscriminate between individuals as no two palatalrugae configurations are alike. Certain rugae
patterns are specific to a particular population andmay also have utility in population differentiation.9
Observing rugae patterns, Selvamani et al foundthat wavy patterns are common in males andfemales, followed by curved and straight patterns.
Circular patterns are very few in number but
significant (P = 0.05).10 Some scientists claim thatenvironmental factors are unlikely to affect theformation of rugae and believe that its patterns are
determined by genes. Genes influence theorientation of the collagen fibers during
embryogenesis and govern rugae patterns indifferent populations.11 Observing the length ofrugae, it appears that primary rugaes are mostprevalent than secondary and fragmented rugaes.12
Examining the types and origins of palatal rugae
according to the Lysell classifications, the study ofBeatrice's (2013) showed that the palatal rugae ofmales is different from that of females. Primary andSecondary rugaes are all found in males comparedto females, whereas fragmented rugaes are morecommon in females than males. Primary rugae
derived from raphae are found in males, whereas
medial origin is found in many women, the study
concludes.
Another study was carried out by Patel to assess
whether there is any hereditary pattern in palatalrugae patterns between the offspring and theirparents. The study showed that there is a positive
correlation of palatal rugae patterns between theoffspring and either of their parents.13
Finally, a study by Indira suggests that thecomparison of palatal rugae patterns among family
members also shows different patterns. Although in
one family few forms were similar, rugae patterns
are not identical. This means that the role ofheredity is uncertain in determining the orientationof rugae patterns.
Conclusion
The patterns of palatal rugae in Minangkabaufamily has the same number of rugae based on thesignificant shapes i.e., curved, wavy, and straight,
and based on the significant length i.e., primary,secondary and fragmented. Because the results ofthis study are rather partial as they rely on a dataconsisting of only 48 individuals from 12 families, amore detailed follow-up study is needed with aEubios Journal of Asian and International Bioethics 28 (March 2018)
larger sample size to reach an ultimate conclusion.
The results of this study indicate that there arehereditary factors in the rugae patterns, whichmakes them very useful for the identification ofindividuals. Chemicals, disease, heat, and trauma
cannot alter palatal rugae patterns. Cheeks, lips,
tongue, buccal pad of fat, teeth and bones protect
palatal rugae from trauma and high temperature.
Although we acknowledge that the limited numberof families studied does not allow us to reach a final
deduction, it is important to note that rugae
patterns may be used as genetic markers forfurther research. We hope this research is acontribution of data in the field of forensic
odontology on individuals, especially ethnics of the
Minangkabau and the Deutro Melayu.
Source of Funding: This research was funded by
the Indonesian Ministry of Research andTechnology (Kemrestek DIKTI) under the Elite
Research Skim of Higher Education. The authors
are grateful to LPPM and the Rector of Andalas
University for faciliting this research.
Conflict of Interest: The authors confirm that there
are no conflicts of interest to disclose.

References

1. Rossum J Van, Krukkert R. 2010. Disaster
Management in Indonesia : Logistical Coordination
and Cooperation to Create Effective Relief
Operations. J Tek Ind;12(1):25–32.
2. Krishnappa S, Srinath S, Bhardwaj P, Ch M. 2013.
Review Article Palatal Rugoscopy: Implementationin Forensic Odontology- A Review. J Adv Med Dent
Scie;1(2):53–9.
3. Saxena S, Sharma P, Gupta N. 2010. Experimental
Studies of Forensic Odontology to Aid in the
Identification Process. J Forensic Dent Scie; 2(2):69–
76.
5. Fahreza Hanifa Akbar. 2014. Perbedaan Pola dan
Ukuran Ruge Palatal Ras Deutro Melayu. Journal
Media Medika Muda.
6. Murao S. 2013. A Cultural Anthropological Study ofBody Techniques for Protection: The Case Study ofIndonesian Minangkabau [1]; 3(3):51–68.
7. Siddique S, Panchmal GS. 2011. Palatal rugae - a toolin forensic odontology. Medico-Legal Update;11(2):55–6.
8. Mustafa AG, Allouh MZ, Alshehab RM. 2015.
Morphological changes in palatal rugae patterns
following orthodontic treatment. J Forensic Leg Med;
31:19–22.
9. Indira A, Gupta M, David MP. 2012. Usefullness ofPalatal Rugae Patterns in Establishing Identity:
Preliminary Results from Bengaluru city, India. J
Forensic Dent Scie; 4(1):2–5.
10. Selvamani M, et. al. 2015. Dimensional andmorphological analysis of various rugae patterns in

45

Kerala (South India) sample population: A crosssectional study. J Nat Sci Biol Med; 6(2):306.
11. Abdellatif AM, Awad SM, Hammad SM. 2011.
Comparative study of palatal rugae shape in two
samples of Egyptian and Saudi children. Pediatr
Dent J; 21(2):123–8.
12. Thabitha RS, Reddy RE, Manjula M. 2015.
Evaluation of palatal rugae pattern in establishingidentification and sex determination in Nalgonda
children; 7(3):3–8.
13. Patel RN, Umesh K, Patel R, Patel N. 2015.
Assessing the inheritance of palatal rugae
patterns;3(6):297–301.

Female genital cutting: aphilosophical exposition- Joseph Nkang Ogar
- Bassey Samuel Akpan
Department of Philosophy, University of Calabar,
Cross River, Nigeria
Email: samuelbassey15@yahoo.com

Abstract

Female genital cutting as practiced in most Africancountries has attracted wide condemnation. This
practice involves partial or total removal of theexternal female genital organ for nonmedical
reasons. Consequently, it causes damage to healthy
or normal genital tissue and thus, interferes with
the natural function of the girls or woman’s body.
Female genital cutting is usually carried out on girls
within the ages of 10 and 22 years old. Most healthexperts attribute so many infections suffered by
women of child bearing age to it. Also, barrenness,
excessive bleeding during child birth or delivery issometimes blamed on female genital cutting. A lotof infections including HIV have been associatedwith this cruel practice. It is the position of thispaper that, such act is barbaric, and a violation of
the human rights of the girl child and womanhood.
Therefore, it should in all quarters be discouraged
and possibly stopped because it violates a person’s
right to health, freedom from torture and security,and integrity.

Introduction

Female genital cutting is a subject that attracts
much concern from many disciplines including
religious, philosophical, sociological, legal andmedical aspects. This kind of practice usually finds
support in some traditional and cultural beliefs. It is
usually performed by traditional practitioners who
have no formal training on the proper use of
equipment and surgical procedures, hence thepractice is both against medical practices and46

Eubios Journal of Asian and International Bioethics 28 (March 2018)

unhygienic. It was observed that implements ortools for these practices include knives, razors andblades made from bamboo trees (Nicoletti 2007).
Again, in most cases it is carried out in the bush or ahighly infectious environment thereby making thevictim more prone to infections and danger. Someenlightened citizens who still want to follow theculture of their people, may still deploy the service
of community health care providers to perpetratesuch barbaric practices. It is the position of thispaper that female genital cutting even if it were to
be carried out in the best hospital in the world, iswrong and should be stopped.
Female genital cutting
Female genital cutting includes various strategies
that include the incomplete or aggregate cutting of
the female outer genitalia as well as damage to thefemale genital organs for social or other nontherapeutic reasons (Nour 2008). Female genital
cutting is portrayed as a traditional practice among
various societies. In studies among the individuals
who practice it, female genital cutting is regularly
ascribed to traditions, albeit different reasons may
be given (for example, reducing ladies' sexualdesires, expanded sexual performance for men andthe health of infants). This practice has existed for along time; it might have been practiced for as longas 5,000 years in some societies (Wade 2012). An
examination in Sudan in 1983 showed that nearly
83% of consulted women affirmed female genital
cutting paying little heed to the type (Alien 2005).
In 1985 a body attached to the UN Commission on
Human Rights, the Working Group on Traditional
Practices Affecting the Health of Women andChildren, uncovered that 54% of people advocating
female genital cutting claimed they do it because itis their tradition (Obermeyer and Carla 1999). A
type of clitoridectomy was practiced in the USA andEurope amid the last half of the nineteenth century;
it was seen as a ‘cure’ for female masturbation andmental illness (Duffy 1963).
Some time ago there was a medical view inwestern nations that clitoral or labial adjustment
was in some cases fundamental to enhance
aesthetic look, upgrade sexual pleasure, solve
matrimonial issues and to cure psychosomatic
sickness (Tepper 2000). A few women’s magazines
advanced such thoughts in the mid-1970s. The
present medical view is that such claims can't be
substantiated (Rushwan 2013). Infibulation is thepractice of excising the clitoris and labia of a girl or
woman and stitching together the edges of thevulva to prevent sexual intercourse. In a few
nations where infibulation is honed, before the lady
is married, it is a customary practice for womenfrom the grooms’ family to visit and examine thebride. The women check to guarantee that the lady

has been infibulated and that she is still a virgin(Ford 2001). In some societies, the woman isprobably going to be alienated and marriage within
her society would be not likely if she is not
circumcised. Toubia explains that for an African
lady who accepts female genital cutting, it is afashionable thing to do to become a real woman
like an American lady who has breast enlarged tolook more attractive. However, “a critical distinctionis that it is principally performed on kids, with orwithout their consent” (Toubia).
Female genital cutting is practiced in more than
40 countries, including 27 African nations, thesouthern piece of the Arab Peninsula and thePersian Gulf (Hosken 1998). It is practiced by a few
people in India, Indonesia, Malaysia and Brazil. The
number of nations where female genital cutting ispracticed is expanding as a result of migrations toWestern nations from nations where female genital
cutting is customarily performed. Nations with
migrant populaces, including the United Kingdom,France, Canada and Australia are such cases. In themeantime about 88% of men sampled randomly in
different countries in Africa support the practice(Leonard 2000). The primary explanations behindendorsement were tradition and religion. Customs
and traditions were by and large acknowledged
beyond a shadow of a doubt. Note that the traditionis bound up with the ethical code of the group andis a critical factor in identification with the entire
group.
In numerous undeveloped nations, particularly
in Africa a lady must be a virgin to be married andher financial survival for the most part may dependon marriage. In the minds of the individuals whopractice female genital cutting, to be different is tobe isolated from the group. Also, a study shows that
Eritrean women trust that female genital cutting
shields them from rape (Bennett 2011). Thus, there
are profound and convincing connections to the
tradition among the people concerned and thoseties won't be easily broken.
Types of female genital cutting
There are basically four major types of female
genital cutting as seen below:
Clitoridectomy: This is said to be the most widely
recognized type of female genital mutilation (Slack1988). This is a partial or total removal of theclitoris, and in rare instances only the fold of skinsurrounding the clitoris is removed.
Excision: in this genital cutting, the clitoris is either
partially or completely removed along side with thelabia minora, with or without excision of the labia
majora, that is ‘the tips’ that surround the vagina(Antonazzo 2003).
Infibulation: The most serious type is infibulation.
This includes removal of all external femaleEubios Journal of Asian and International Bioethics 28 (March 2018)
genitalia. The whole clitoris and labia minora and asignificant part of the labia majora is removed or
scraped (Weston 2017). The remaining raw ends ofthe labia majora are afterward sewn together. In
remote areas acacia tree thistles are used and heldin place with catgut or sewing string. Sometimes aglue of gum arabic, sugar and egg, is utilized toclose the vulva. The whole area is closed with only alittle opening, about the measure of a match stick,left to pass pee and menstrual liquid. A straw, stickor bamboo is embedded in the opening so that as
the injury recuperates the tissue won't growtogether and close the little opening. As of late in a
few territories, a few persons who play out thesystem sew together the labia without cutting(Antonazzo 2003).
Others: Includes all other harmful procedures tothe female genitalia for non-medical purposes suchas pricking, piercing, incising, scraping andcluttering of the genital area (Ekeke 2010:161).
Arguments for female genital cutting
Some reasons have been presented to justify why
many cultures in Africa and Asia still practice thisbarbaric and dehumanizing practice not minding
the wide condemnation by the World HealthOrganization (WHO).
Family autonomy: The general right of parents tochoose what is best for their youngsters has existed
for a long time and there is a desire that the State
won't meddle in choices which are in the area ofindividual families. In other words, the “privacy” ofthe family has by and large been ensured by society(Petronio 2013: 46).
The right to cultural integrity: The individuals
who defend the privilege of parents to have theirlittle girls "circumcised" allude to their customaryvalues and their entitlement to cultural integrity
without impedance from people who hold different
customary values. Notwithstanding, there is adistinction between neo-colonialist endeavors toforce western human rights norms on Third World
nations and social practices which are the same aspractices in the West through which ladies arerespected less than men (Regier 1991).
Psychosexual argument: To this group, female
genital cutting is encouraged as an activity orpractice aimed at curbing women’s sexual desires.
According to this, if only the prepuce of the clitoris
is removed, it automatically reduces the female’s orwoman’s sexual desire and by this guarantees her
chastity or staying or maintaining her virginity until
she is married (Carr 2015). To Osarenren, female
genital cutting or mutilation should be sustained
because it encourages fidelity as such as practicestops women from getting sexually aroused (Carr
2015: 163). But the question here is whether thisheinous practice has successfully tamed women47

because experience has shown that woman who
wish to be promiscuous have not stopped being so
on excuse of genital mutilation. The psychosexualargument leaves us with little to be desired. And
rather leaving us to think that chastity, fidelity orotherwise being promiscuous is related to humanwill and choice, rather than praised or blamed on
the removal of the clitoris (Ogar and Asira 2011:327).
Mythological argument: This argument hinges onsuperstitious beliefs surrounding the practice.
Especially those of Yoruba is the perceived belief
that when the clitoris is not cut, it will harm thefetus when it touches it during child delivery. Also,
there is the belief that if the clitoris is not cut, it willgrow to the size of a penis (Toubia). But as we allknow, superstitious beliefs have not been provenscientifically. Again, no established case of female
infertility has been traced to not cutting of thegenitalia. Hence, this argument is less satisfactory
as built on superstition.
Religious argument: Despite the serious
campaigns against female genital cutting byactivists and healthcare workers, this argument is
one of the most potent one in support of the female
genital cutting. In Africa for instance, many
practitioners of traditional religions see it as one of
the rites of passage required by their religion. Thatis a necessary condition to be fulfilled by young
girls who are about to pass from puberty toadulthood in preparation for marriage (Toubia).
According to this argument, this practice is done to
reduce a women’s libido, so as to help her resist
illicit sexual act which is a taboo with theconsequences of bringing the wrath of the gods
against the community. According to this position
when a virginal opening is covered or narrowed,
the fear of pain of opening it, alongside the fear that
this will be found out, is expected to further
discourage illicit sexual intercourse among womenwith this type of female genital cutting (Rushwan2013). However, World Health Organization (WHO)debunked this as lacking credibility, merely
motivated by beliefs about what is considered
proper sexual behavior related to premaritalvirginity and marital fidelity (Toubia). Neither the
Christian or Islamic religion has any doctrinal basis
for female genital cutting. This scripture referencein Genesis 17; 10-12 is made specifically to the(male gender), and not (female gender). ‘This is mycovenant with you and your descendants after you,the covenant you are to keep. Every male among
you shall be circumcised on the 8th day of birth.
While Abu-sahieh argued that there is no doctrinal
basis for female genital cutting in Islam andChristianity. Therefore, there is no substantive
evidence that female genital cutting is a religious
requirement (Gronnvoll 2008).

48

Eubios Journal of Asian and International Bioethics 28 (March 2018)

Social argument: This argument is a result of
wanting to work in conformity to the social
behavior of peers. That is, being attune with thepractices of the time and community. Female
genital cutting in some cultures is a qualification or
requirement for participation and enjoyment of fullprivileges and rights to the female folks in thecommunity. In some communities, a woman whose
genitalia are not cut, would be denied marrying any
man in the community because they interpret uncut
clitoris as a penis in a woman which mustnecessarily be cut to show that she is a woman(Bennett 2011: 136). This position is indeed
abnormal because given an understanding between
the function of penis in men and clitoris in women,no matter how big clitoris may be, it can never
become penis and vice versa. So it is an unfounded
position that lacks evidence.
Aesthetic argument: In Kenya like in many
communities in Nigeria and Africa at large, thisunhealthy trend of genital mutilation is still highly
upheld. They maintain the position that unless afemale or woman clitoris is cut, she is sacrilegious(Bennett 2011). This argument upholds the viewthat until the female clitoris is cut, she is not truly
beautiful and is followed with grim consequencessuch as causing a lack of arousement or feeling ofsex even when they are married with the result thatmany of them end up in broken marriages becauseof constant or near constant sex apathy in theirspouses.
Medical and ethical arguments against
female genital cutting
There are numerous immediate and long haul
health results of female genital cutting, both
physical and mental. Inconveniences from themethod can bring about barrenness. Issues canremain with the girl into adulthood and prompt
obstetrical challenges which imperil the life of both
the woman and her wards. It is likewise understood
to be regular for infibulated ladies to under-eat
amid pregnancy with the goal that they will havesmaller kids. Doctors in Sudan have evaluated thatthe number of fatalities because of infibulation isaround 33% of all young ladies in zones where antiinfection agents are not accessible (Lyman 2013).
Death because of female genital mutilation is oneof numerous variables adding to the high infantmortality rates in these nations (Slack 1988). For
instance, Somalia, which has one of the highest
rates of circumcised ladies on the planet, has theworld's fourth most noteworthy high infantmortality rate (Nour 2008). The medical issues
related with female genital mutilation are more
noteworthy with clitoridectomy and infibulation
because these procedures include more radical
surgery. The health impacts of female genital

mutilation,
particularly
infibulation,
canincorporate acute infection, shock, hemorrhage(attributable to the instruments utilized andmedications set on the injuries), tetanus, harm tonearby organs, death, and septicemia. Most times
after infibulation the young lady's excrement iscaught by bandages and this fuels different
complication issues.
It has been proposed that more than 100 million
women are “missing” in Africa and Asia as a resultof an absence of medications, health care andnourishment (Slack 1988). A huge proportion ofthese could well be ascribed to the act of female
genital mutilation. Numerous young ladies bleed todeath in light of the fact that clumsy operators havecut into the pudendal corridor or the dorsal vein of
the clitoris. Other young ladies die of post-operative
shock because of not being able to revitalize thegirls or take them to the doctor’s facility or center(Pauls). Studies in Sudan demonstrate that all
infibulated women detailed critical issues inurinating. The normal timeframe it takes aninfibulated lady to urinate is 10-15 minutes (Nour2008). They need to compel the urine out drop bydrop. Extreme infections can prompt incontinence.
Sometimes the gap left after infibulation is too little
and keeps the stream of menstrual blood which
gathers in the abdomen.
There have been occasions where young ladies
have been murdered to safeguard their family's
respect when the swelling of their bellies and thenonappearance of feminine cycle have been
wrongly translated as pregnancy (Armstrong 1999).
In an examination in Sudan in 1983 it was
discovered that almost all infibulated womenannounced anguishing periods, in which themenstrual stream was blocked to some degree. Thisbrought about clotted tissue requiring surgicalintervention (Armstrong 1999). Troubles inchildbirth for infibulated women happen much of
the time and can be serious because of scarring andsolidified tissue hindering the section duringchildbirth. Deferred births are normal and there
can be brain damage and death of the infant due toabsence of oxygen. Sometimes the lives of both themother and youngster can be undermined in lightof the fact that the opening is too small (Slack 1988).
There have been few investigations of the fullmental outcomes of female genital mutilation todate, however suicides have been accounted foramong young ladies in Burkina Faso (Youngblood2014). Slack proposes that such extraordinary
torment in an amazingly sensitive, unpredictableand vital physical zone, when experienced by young
ladies in their developmental years could bringabout significant mental issues (Slack 1988).
Whether these issues would cause emotional
damage isn't clear. When they are mature enoughEubios Journal of Asian and International Bioethics 28 (March 2018)
to understand what female genital cutting includes,
the young ladies regularly experience nervousness
before, and in expectation of the procedure. The
occasion itself is likewise alarming as the young
ladies are held down by force and frequently no
pain reliever is utilized. Torment is said to keep
going for quite a long time and may continue
throughout life; for instance, the pain of
menstruation, intercourse amid the primary
periods of marriage and at labor (Slack 1988).
Before having the procedure done, thecontention of sentiments in the child are said to be
impressive. From one viewpoint, there is the desire
to please guardians, grandparents and relatives byaccomplishing something that is exceptionallyesteemed and endorsed of; and there is a desire to
be normal. The feeling is compared to the young
lady’s expectation of torment, the stories of anguishand the sheer dread of hearing the shouting ofother girls being circumcised. At last, there issimply the experience: being held down with force
while part of the body is cut off (Toubia).
The clitoris is an essential female sexual organ.
The tip of the clitoris has a thick supply of nerve
endings which are extremely sensitive to the touch.
The vagina has limits with regards to sexual
reaction. Therefore, female genital cutting aims toevacuate the lady's sexual organ while abandoning
her conceptive capacity in place (Toubia).
Following marriage the spouse must penetrate theinfibulated vulva. Regular penetration istroublesome and an opening must be made with ablade or knife. Some ladies experience a slow
procedure of entrance which can take a few months.
In a few nations the infibulated vulva is opened
routinely with a blade before marriage is concluded.
In Somalia the spouse utilizes his fingers, a blade ora razor to extend the opening in his wife. In
different societies the spouse’s mother or grandma
measures his penis, makes a wooden copy of asimilar size and cuts the infibulated opening of thebride as needed. This permits penetration, which inthe beginning will be frequent, to keep the opening
injury from closing once more (Slack 1988). On
account of infibulation, the primary reason is by all
accounts to ensure the bride’s virginity. The small
opening left after infibulation makes sex for all
intents and purposes unimaginable without
reviving the vagina.
Women’s and children’s rights: Female genital
cutting is a critical infringement of human rights especially ladies and children’s rights - and results
in serious difficulties, including but not limited todeath, premature delivery, disability, sexual
dysfunction, stillbirth, hemorrhage, discharge,
sepsis and post-traumatic stress disorder.
Distinctive researchers have examined humanrights harmed by the act of FGM. For instance, Efua

49

Dorkenoo contended that female genital mutilation
is an exhibit of sex based human rights
infringement, which means to control women's
sexuality and flexibility (Laurance 2014).
Right to health: The International Human Rights
law including the Universal Declaration of Human
Rights (1948) advocates the privilege for every
single individual to live in conditions that enable
them to appreciate healthcare and good health. The
issues related with the methodology of FGM
frequently have brutal results for a woman’s
physical and emotional well-being. A wide range of
FGC caused health complexities result from thetechnique frequently being performed outside
healthcare facilities by non-experts utilizing
unsterile cutting instruments (Evans 2002).
The privilege of the child: The casualties of thisunsafe conventional practice include children andyoung girls. Joined States Department of State,
Ethiopia additionally contended that FGM
disregards the privileges of children since it isgenerally performed on young women. This implies
the practice of FGM negates Art. 3 of CRC which
instructs that “…the best interests of the child shallbe a primary consideration which is a central
notion of the Convention on Rights of Child’’ (Riggio
2002).
The privilege to sexual and physical integrity:
Female genital cutting damages the privileges ofwomen and girls to sexual and physical respect(Johnson 2002). Violations of the privilege tophysical integrity are most evident when girls andwomen are coercively controlled amid theprocedure. FGM is performed without women andgirls full conent. An unapproved attack onsomeone’s body speaks to elimination of that basic
right.
Right to be free from discrimination: The act of
FGM is likewise sex-based victimization for
marriage. Many persons will allow it since it isessential to increase financial and social security.
For example, in Gikuyu society there is aconvention that disallows men to wed
uncircumcised women (Helland 2013).
Freedom from torment, unfeeling, barbaric anddegrading treatment: The UN Special Rapporteur
on Violence against women has unmistakably
expressed that FGM adds up to torment. The report“views cultural practices that involve pain andsuffering and violation of physical integrity” asamountingtotortureunder
customaryinternational law, attaching to such practices strict
penal sanctions and maximum international
scrutiny regardless of ratification of CEDAW or
reservations made thereto (Morgan 2015).
Generally, FGM is a customary hurtful practicethat disregards the rights and dignity of ladies andgirls, the rights to wellbeing and life (in cases where

50

Eubios Journal of Asian and International Bioethics 28 (March 2018)

it results in death), sexuality and physical respect of
the individual, and the privilege to be free fromtorment and degrading treatment.

Conclusion

The paper, after a careful analysis and evaluation of
the subject of female genital cutting with reasons tojustify such pratices such as religious, social,
psychosexual, mythological and aesthetic, found allas lacking credibility in their arguments, leaving
women with long and short terms consequences
like excruciating pain, loss of blood resulting inanemia, hemorrhage, shock, infections, fibrous scar,shrinking of artificial opening in virginal, pelvic
pain, sex phobia, depression, anxiety, etc. This ugly
trend has no medical support, neither has it any
sustained social and scriptural justification for such
cruelty against females. It is the position of thispaper to conclude that female genital cutting is
unequivocally inhumane, hence a clarion call on
women activists to step up their effort and advocate
it outright condemnation.

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Bases of Early Marriage &Consequences on the Well-being ofMother and Child in Jhirubas, Palpa,
Nepal- Bikash Thapa, MBGPH
Executive Member, Youth’s UNESCO Club, Nepal

Email: bthapa1985@gmail.com- Darryl Macer, Ph.D., Hon.D., MPH
President, American University of Sovereign Nations,Arizona, USA
Email: provost@ausn.info

Abstract
This research explores the causes of earlymarriage and assesses the consequences of earlymarriage on maternal and child well-being in a
district of Nepal. A two week long field operation
was carried out to collect data where 126
respondents were selected through conveniencesampling methods on the basis of two criteria,
including 1) being a married women only who got
married before 19 years of age; and 2) those whohave children below three years. The interviews
were mainly focused on those who have a neonatal
child. A structured interview schedule found thatearly marriage is still prevalent among the illiterategroup. A paradigm shift was found in some aspects,
such as the shift in decision-making from parents tochildren, a shift from arranged to love marriages,
and from parental pressure to marry to love andfulfillment of sexual desire as reasons for marrying.
Most of the respondents have no idea about thelegal marriage age and punishment for underage
marriage. Most of the respondents suffered fromdifferent physical health-related problem including
poor maternal and child well-being, weakness,
immaturity, miscarriage, sexual problems, no
prenatal check up, and/or low birth weight.
To deal with the problem a number of strategies
have been suggested, mainly providing economic
opportunities to young girls, improving thestrictness of legal strategies about marriage age,
promoting education of girls, and using mass media
to increase the awareness of the whole community
about the consequences of early marriage on girls
themselves and on her children along with their51

family. Efforts need to be made in the communityand other parts of Nepal where early marriage andchild marriage is prevalent.
1. Early Marriage in Nepal
Early marriage, also referred to as child marriage
or entitled marriage of young adolescents remains
prevalent in many parts of the world despite
repeated efforts by national governments andinternational development agencies to discourage
and end the practice. According to the State ofWorld Population Report 2005, 48% of women in
Southern Asia, and 42% of women in Africa in theage group 15-24 years had married before reaching
the age of 18 years of age (UNFPA 2005). Early
marriage is likely to lead to early pregnancy andassociated health risks for the mother and the child;and force the marriage partners, especially thebride, to terminate schooling prematurely (UNICEF
2001; UNICEF 2005).
Nepal is placed among the least developed
countries of the world. The poor health and wellbeing status is one of the main problems of the
Nepalese society. Nepal, being a slow progressing
country, faces various well-being and healthproblems. The major well-being and healthproblems in Nepal are malnutrition, high childmortality rate, maternal mortality rate, rapid
growthofpopulation,
earlymarriage,environmental pollution, lack of health facilities
and health service, high prevalence ofcommunicable disease, lack of education andinformation, and so on. The demographic variables
like fertility and mortality are responsible forpopulation growth. Mortality has been playing avital role in determining the growth of population.
The growth of population affects well-being, health,education, social security, ecological condition,
economic condition and cultural entity. Therefore,
the population itself has become multi-dimensional
factors in the socio-economic setup of a country.
Nepal has passed a law of marriage age.
Previously it was 20 years of age without consent of
parents and 18 with consent of parents. Now it is
20 for both male and female. Beyond that if any
person (male or female) does and/or a third person
is involved in making marriage under age it isagainst the law and shall be punishable. Many
researchers here show that there is a higher rate of
miscarriage among early child bearers under theage of 18 years as child and early mothers.
Therefore, there is an extra risk to child andmother’s health. Presently according to theConstitution of Nepal, “Forcing children, especiallygirls, into early marriage can be physically andemotionally harmful”, UNICEF Executive Director
Carol Bellamy said in a statement “It violates their

52

Eubios Journal of Asian and International Bioethics 28 (March 2018)

rights to personal freedom and growth” (UNICEF,
1992).
Early has been defined the World HealthOrganization as the period of life spanning the age
between 13 to 19 years. Early is a period oftransition from childhood to adulthood. Early is adistinct and dynamic phase of development in thelife at an institutional. There are the formative
years when maximum amount of physical,
psychological and behavioral change take place.
Thus, the future of the Early depends upon how
their growth and development take place (WHO,2001).
Marriage is an important part of human life. It is
an institution, which demands maturity, capacity
and responsibility. Young girls still in her childhood
cannot be expected to appreciate the union called
marriage and to know conjugal bliss in an enforced
early marriage. The physical and emotional trauma
she has to undergo in comparable to that of thevictim of any heinous crime and she ends of leadinga repressed, insecure and submission existence.
Early marriage referred to child marriage isdetermined by culture, education, economic status,
social status, character, love and honors, enjoyment,
discrimination, and so on, and one of theconsequences of early marriage is that it leads toearly pregnancy. This is a health risk for young
woman and children. Rapid growth in population
creates problems in education, economic status,
social adjustment and also physical and mental
health. Early marriage invites or develops higher
maternal and child mortality rates, and a higher
rate of abortion.
Early marriage is the most common social
problem in developing countries like Nepal. In
Nepal, 138,015 have married below 10 years and7,880,398 married during 10-19 years among
13,338,496 married couples (CBS 2011). According
to the Nepal Family Health Survey in 2016, 22% of
women have ever experienced physical violencesince age 15. Furthermore, women also die of directcauses that are aggravated by pregnancy.
Furthermore, a large number of women suffer from
infections and disabilities related to pregnancy andchild birth. The maternal mortality rate has become
one of the major health problems of Nepal.
Early marriage has numerous adverse effects on
the overall health of a girl child who is not mentally,
psychologically, emotionally or physically notprepared for a marital life and must be eliminatedfor its numerous adverse consequences on society.
Early marriage deprives her of an opportunity ofstarting or continuing her education and deprives
her possibility to develop her own personality andpotentiality. Once married, she is expected to get
into the multiple roles of good wife, perfectdaughter in-law, diligent housekeeper andresponsible mother. This transition can be
psychologically and emotionally stressful for ayoung girl. Deprive as a child and lacking maturity
skill to handle her personal, family, economic andsocial affairs the young wife develops fears
complexes that last her whole life.
The health and well being practice is different
from community to community. Well-being statusof Nepal community is very poor as in many least
developed countries. Nepal has economic problems
community consuming health and health services.
The present study is based on a community in
Jhirubas VDC of Palpa district.
The study area is a remote area where its
inhabitants in Jhirubas VDC are furthermore
backward regarding health and well-being service
and facilities. The majority of the local peoples are
Janajati and Dalit in origin, and few of them arefound from different communities such as
Brahmins or Kshetries. Early marriage is common
in Palpa district. 1,195 and 79,973 got marriage on
or below 10 years, and between 10-19 years
respectively among 207,031 married couples (CBS2011). In the context of JHIRUBAS VDC, there is the
problem of early marriage because of customs andother many reasons such as ignorance, poverty,
culture lack of education, discrimination, and so on.
It is known that early pregnancy and earlymarriage is one of the high risks. Every year at least
585,000 women in the world die from thecomplications of pregnancy in many developing
countries, which leads as a source of maternal andchild death. The major health problems of Nepal arehigh maternal and child mortality, prevalence ofcommunicable disease, high fertility rate, poor
health care practice, environmental pollution, rapid
population growth, and so on (UNICEF, 2002).
In Nepal, 11.25% of girls are married before their
14th birthday (CBS 2011). Adolescent pregnancy
below the age 18 year is 2-3 times more likely to
die than the pregnant women between 18 to 25
years. Low birth weight is also more common
among babies from adolescence than those women.
In Nepal, early marriage system is still acceptedthough the legal age of marriage is 20 years orabove. As a result of child bearing at an early age
includes low birth babies that is a complication toboth mother and child (Save the Children, Plan
International, 2012).
In the hilly region, a 14-18 year old girl iscommonly married. The risk of complications
during pregnancy period is more because the girls'
bodies are not fully developed under 18 years old.
There are various determinant factors of earlymarriage like as lack of education, lack ofawareness about early marriage, economic status
or poverty, conservative beliefs or culture, social
status or backward community who has not got anEubios Journal of Asian and International Bioethics 28 (March 2018)
opportunity for a good life style. These create manybad consequences like low weight baby, high MMR
frequency, morbidity and infant mortality andinvites serious problem to the well-being of motheras well as child. It can be minimized to the extent by
the relevant knowledge about early marriage andmany kinds of opportunity to develop their carrier
and further progress. The system of early marriage
causes a high risk of pregnancy and affects thehealth of mother and child. The main cause of theirhealth status due to early marriage is not known.
Therefore, this study sought answers to thefollowing questions:
1. What are causes of early marriage in studyarea?
2. What is the consequent of early marriage on
the women and children of study area?
3. How can these underlying reasons for childmarriage be combated?
This study was limited to the people in Jhirubas
VDC of Palpa district which is the hilly area of Nepal
and most of the peoples are Dalit and Janajati inorigin with backward and weak health practices.
These limits include:
1. Only early married (married before 19 years)
women in Jhirubas Palpa district were selected
for the study.
2. This study was limited to the women up to 30
years and with a child less than 3 years.
3. The study identified only the causes of earlymarriage and its consequences on mother andchild well being.
Operational Definition of the Terms Used

Adolescence: Life spanning age between 10-19 years(WHO)
Causes: Factor leading to teen-age marriage in theCommunity
Community: Community of social group within the somedegree of social coherence and living in given area.
Consequences: Impact
Household: All the people living together in a house isdefined as a group of people related by blood. Marriage,or adoptions that have a common residence
Immunization: It is process of taking medicine forincreasing immunity artificially against the infectious
diseaseLow Birth Weight: An infant’s birth weight generally isless than 2500 grams.
Maternal Morality: It is the death of women while
pregnant or within 42 days of termination of pregnancy
irrespective or its management but accidental orincidental causes.
Morbidity: It means incidence and prevalence of any
disease to mother.
Pregnancy: The condition of having a developing embryoor fetus in the body after union of an ovum and sperm. In
women, duration of pregnancy is about 280 days or
stage of women having a growing baby inside womb.

53

3. Patriarchy and Cultural Pressures
Feminists use the term patriarchy to describe thepower relationship between men and women as
well as to find out the root cause of women’s
subordination. According to Walby (1990:9),
patriarchy is indispensable for an analysis ofgender inequality. She further argues that there are
six patriarchal structures which restrict womenand help maintain male domination, and these arepaid work relations within the household,
patriarchal culture, sexuality, male violence
towards women and the state. In terms of theirinterrelation, Walby argues that each of thesestructures impacts upon one another but are also
relatively autonomous. Their interrelationships
constitute the different "forms" of patriarchy
present in a particular society (Haralambos andHolborn, 2008:1).
In the patriarchal nature of south Asian culture,value is placed on the boy-child’s education thanthat of the are subordinated and undervalued suchthat girl-child. Girls do not have equal educational
opportunities to boys. Although, the Government of
Nepal has endorsed laws and signed many
international conventions to overcome thisproblem, due to weak enforcement of law and low
level of people’s awareness, still much remains to
be done on this issue.
In homes where there is poverty with few
financial resources, girls will be forced to drop outof school prematurely in favour of the boys. This isbecause some parents believe that boys are more
intelligent, that they perform better in school andthat they are a better educational investment than
girls (Odaga and Heneveld, 1995:22). A factor often
ignored in discussions of parental preference forboy's education is the prevalence of patrilineal
inheritance systems. As the prime beneficiaries offamily assets, boys are favoured in human capital
investment decisions. In addition, parents worry
about wasting money on the education of girls who
are likely to get pregnant or married before
completing their schooling (Odaga and Heneveld,
1995:23). Also in most African cultures, girls weremeant to be housewives, mothers and homemakers doing domestic duties. The boys were to behousehold heads and the breadwinners or
economic providers of their homes and this meantthat they were to be educated and acquire wealth tomanage these homes (Were, 1991:2). Therefore,
gender roles assigned to girls by the family, andsociety, are geared more towards marriage thanattainment of educational success.
Patriarchy hinders women and girls from being
involved in development activities in the society.
Culture is a product of patriarchy and in patriarchal
societies, it is the system which makes men to
become rulers over their wives and this means

54

Eubios Journal of Asian and International Bioethics 28 (March 2018)

women do not make decisions in both public andprivate spheres. A woman cannot decide on thenumber of children to have and when to have themand also who among girls and boys should go toschool, and in most cases girls do not go to school.
Therefore, based on the provisions of patriarchy,
there are benefits that men acquire from earlymarriages and these marriages ensure maledominance and female subordination in Nepalesesociety and even obstruct the children rights toattain a nurturing family environment.
In Nepal, due to religious and cultural pressure,marriage take places early among all ethnic groups,
and many Nepalese women marry on their 19thbirthday (NCP, 1990). Aryal (1995) mentioned thatage at marriage is an especially important variableaffecting fertility in a society. Where fertility out of
wedlock is strongly disapproved and marital
dissolution is insignificant. Therefore it is anespecially important variable shaping the fertility
level in Nepal wherever few births take placeoutside of marriage and maternal dissolution is
insignificance.
WHO (1996) reported that the life risk of dying ofpregnancy or child birth is one in twenty in somedeveloping countries compared to one in ten
thousands in some developed countries. The age at
which women being is to start child bearing, theinterval between each birth, total number of life
time pregnancy and socio-cultural and economic
circumstances in which women’s life influencematernal morbidity and mortality.
First marriage marks the point in women’s life atwhich childbearing becomes socially acceptable.
Women who marry early will have, on average,
longer exposure to the chance of becoming
pregnant and, therefore, early at first marriage
often implies early age at child bearing and higher
fertility for a society (MOH, 1996:81).
WHO (1997) reported that until recently,
adolescent and youth were not considered as animportant issue in any kind of policies andprograms in many Asian countries. In the late1980s, the world community formally recognized
how seriously the health of young people impacts
on the health and development of future generation.
The World Health Assembly passed a special
resolution in Many 1989 urging member states togiven priority to the health needs of adolescent andyouth and to develop socially acceptable programs
and services to meet these needs
Shakya (1997) found that decreasing age atmarriage will have a depressing effect on thenumber of younger women who are exposed topregnancy. Delayed marriage is the major
contributor to reduce fertility. In Pakistan the
educated women had higher age at marriage andlower fertility. It was noticed that there has been an

increase in female age at marriage from 15.4 to 18.1
between 1961 and 1981 in Nepal. This hasapparently been achieved mainly due to thetendency of younger persons to postpone marriage.
There may be combination factor and contributing
to this. Expansion of literacy, education and wellbeing services, development of other sector. Such astransport and communication, the increasing
urbanization and the fixation of the legal minimum
age at Marriage may have all contribute to therising age at marriage.
Gubhaju (2002) mentioned that motherhood at avery young age entails a risk of maternal mortality.
The children of young mothers tend to have higher
level of morbidity and mortality. Early child bearing
continuous to be an implement to improvement in
the educational, economic and social status of
women all parts of the world
The Fifth Asian and Pacific Population Conference(11-17 December, 2002, Bangkok) stated that
Nepal has high fertility rate among adolescents
over all, 21% of adolescents girls aged 15-19 are
already become mother are pregnant with theirfirst child. The age specific fertility rate in bothurban and rural is highest among 20-24 years age
groups. The practice of early marriage is a major
factor responsible for relatively high proportion ofadolescent child bearing in Nepal contributing tohigh maternal mortality. The adolescent girls havetremendous nutritional deficiencies, which may
affect their children resulting infants low weightbirth, disabilities or death. With repeatedpregnancies they face anemia, continued
malnutrition and excessive workload which can
result an early death. “Forcing children, especiallygirls, into early marriage can be physically andemotionally harmful”, UNICEF Executive Director
Carold Bellamy said in a statement “it violates theirrights to personal freedom and growth”.
According to Muluki Ain Civil Act (Country Code)new revision Mahal 17 Behabariko 221: The legal
age of marriage is 20 for both men and women,
Further, the law states that punishment for childmarriage is imprisonment for up to three years anda fine of up to 10,000 rupees.
Nepal has made important steps over the past
few years to promote gender equality, butaccording to report of UNICEF published in 2017,
the country still has one of the highest rates of childmarriage in the world. 37% of Nepalese girls are
married before the age of 18. Moreover previously,
the 2015 earthquakes devastated the country andleft girls and women in an increasingly vulnerable
position, leading to fears that child marriage rates
may increase over the next year.
NDHS (2016) reported that overall, 17% of
women aged 15-19 had begun childbearing: 13%
had had a live birth. The proportion of teenagers

Eubios Journal of Asian and International Bioethics 28 (March 2018)
who had begun childbearing rose rapidly with age,from 2% at age 15 to 36% at age 19. Moreover,rural teenagers tend to start childbearing earlier
than urban teenagers
NDHS (2011) also found that 82% of all deaths
among children under age 5 in Nepal take place
before a child’s first birthday, with 54% occurring
during the first month of life . Likewise, same
report stated More than half (52%) of women are
married by age 18, compared to 1 in 5 men (19%).
Which may be the reason as 11% of women begin
sexual activity before age 15, while 51% have sex
before age of 18 years of age. So the% of women
who got married before 18 years is higher. So,
adolescent fertility rate (AFR) in Nepal is 81 per
1,000 girls. In 2015, the number of births per
thousand women between 15 and 19 years old in
Bangladesh amounted to approximately 83 births.
Save the Children (2004) reported a strong
association between child marriage and earlychildbirth, partly because girls are pressured toprove their fertility soon after marrying and they
have little access to information on reproductive
health or ability to influence decision making onfamily planning (Mathur et al., 2003; Blesdoe andCohen, 1993; Mensch, Bruce and Greene, 1998;
Malhotra et al., 2003). One third of women indeveloping countries give birth before 20; and inWest Africa, as much as 55% of women give birth
before 20.
FCI and the Safe Motherhood Inter-Agency Group(1998) and CDC (2002) reported that women whobear children at a young age may face serious
health consequences. Young mothers experiencehigher rates of maternal mortality and higher riskof obstructed labor and pregnancy-induced
hypertension because their bodies are unpreparedfor childbirth (Save the Children 2004; Mathur, etal., 2003). Girls between 10 and 14 are five times
more likely than women ages 20 to 24 to die inpregnancy and childbirth (UNFPA and the
University of Aberdeen, 2004). Girls aged 15 to 19
are twice as likely as older women to die fromchildbirth and pregnancy, making pregnancy theleading cause of death in poor countries for this age
group (Save the Children, 2004). In Mali, forexample, the maternal mortality ratio is 178 forevery 100,000 live births of women ages 15 to 19,
compared to only 32 for women ages 20 to 24.
UNFPA and the University of Aberdeen 2004
stated that women who bear children at a young
age may face serious health consequences. Youngmothers experience higher rates of maternalmortality and higher risk of obstructed labor andpregnancy-induced hypertension because theirbodies are unprepared for childbirth (Save theChildren, 2004; Mathur et al., 2003). Girls between
10 and 14 years of age are five times more likely

55

than women aged 20 to 24 years to die inpregnancy and childbirth.
Girls who have babies also have a high risk of
suffering from obstetric fistula, a condition in which
the vagina, bladder and/or rectum tear duringchildbirth and, if left untreated, causes lifelong
leakage of urine and feces (UNFPA and Engender
Well-being, 2003). Two million women suffer fromobstetric fistula worldwide, and an additional
50,000 to 100,000 new cases develop annually
among girls (Murray and Lopez, 1998).
Save the Children (2004), and Kurz (1997)
reported that the children of teen mothers
experience serious health consequences as well. A
child born to a teen mother is twice as likely to die
before the age of 1 as the child of a woman in her
20s. Currently, 1 million infants of young mothers
die every year worldwide as a result of pregnancy
and childbirth-related causes. If they survive, these
infants tend to have higher rates of low birthweight, premature birth and infant mortality thanthose born to older mothers (Save the Children
2004). After birth, infants of teen mothers are more
likely than infants born to older mothers to havepoorer health care and inadequate nutrition as aresult of their young mothers’ poor feeding
behavior.
UNICEF (2005) stated that girls who are married
young often lack status and power within theirmarriages and households, and so are more likely
to experience domestic violence, sexual abuse, andisolation from family and community (UNICEF
2005; Jenson and Thornton 2003). A survey in India
found that girls who married before 18 reported
experiencing physical violence twice as often as
girls who married at a later age; younger married
girls reported experiencing sexual violence threetimes more often (ICRW 2005). Girls who marryyoung are also more likely to believe violence isjustified. A useful report is New Insights on
Revenging Child Marriage: A Global Analysis of
Factors and Programs (UNICEF 2005; Ensign andThornton, 2003). A Kenya study found that 36% ofgirls who married before 18 believe that men are
justified in beating their wives, compared to 20% of
those who married at a later age.
Pathfinder International/Ethiopia, (July, 2006)
mentioned that in Ethiopia, early marriage is seen
as a way to improve the economic status of thefamily, to strengthen ties between families, toensure that girls are virgins when they marry, andto avoid the possibility of a girl reaching an age
where she is no longer desirable as a wife (“Qoma
Qerech”).
Acharya (2010), Glasier (2006), Plourde (2012)
explained that 'adolescent pregnancy brings lost
potential’ (UNFPA, 2007a). Furthermore, it may
bring many negative health and social effects for

56

Eubios Journal of Asian and International Bioethics 28 (March 2018)both mother and child. UNFPA (2007a) suggeststhat when girl aged 15-19 years becomes pregnant,they are twice and adolescent under 15 are fivetimes more likely of dying during pregnancy orchildbirth compared to woman over 20 years.
School dropout, premature infant deaths, unhealthy
children and more children in a shorter period oftime can be seen.
Pokherel (1989) found in her study that about
one third of women marry early. Dipya (1992)
found that majority of the women smoke during
pregnancy due to lack of education and most ofthem undertake heavy works due to poverty.
Chhetry (1993) mentioned that marriage usuallytakes place at very early ages in Nepal. Tuladhar(1997) conducted a study of 200 early mothersfrom Tribhuvan University Teaching Hospital(TUTH) and maternity hospital Patan andThapathali. Results from that study showed that themean age of delivery is 18 years and minimum age
was 15 years. Among all early mothers, 60% wereliterate and 57% mother's age of marriage was 12
years.
Lloyd and Mensch (1999) showed education is
widely credited as the most significant factor fordelaying girls’ age at marriage (Mathur et al., 2003;
United Nations Commission on Population andDevelopment, 2002). Over the last several decades,
parents have come to value education for theirchildren, and to be willing to postpone themarriages of their daughters so they can attain ahigher education level (Schuler et al., 2006). It isthought that education enhances girls’ autonomy,
giving them negotiation skills in choosing a partner
and influencing the timing of marriage (Lloyd and
Mensch, 1999; NRC/IOM, 2005). Education also isbelieved to increase girls’ aspirations and extend
the process of finding a suitable marriage partner.
Ghimire (2001) found in her research area that
13% women got married below than 15 years, 50%
women get married in the age of 16-19, which areconsidered as early marriage, 30% and 7% women
got marry in the age 20-24 and 25-30 years,
respectively. It is found that the causes of earlymarriage mainly are tradition, 76.67%.
Subedi (2001) revealed that early marriage wasfound to have high prevalence, more than 50% of
the total respondents got married between 10-18
years and 78% got their first pregnancy in this age
group. Immunization status of children under 5
years was found very poor, with diarrhea disease,malnutrition and ARI being the most common
diseases.
Mothers are mostly suffering fromswelling, heavy bleeding and lower abdomen pain.
Indira (2004) found that early postnatal mothers
who delivered the babies of 2500 grams or lessthan it at birth.

Shah (2004) reported that 95% respondents had
got married before 16 years and 5% before 20
years. 72% mothers delivered babies at home.
Mahara (2006) mentioned that age at marriage
found 50% in 13-15 years and 30% in 10-12 years,
more than 70% of women had not known laws
about early marriage. 20.69% children died in the
13-15 years age group of mother, 48.55% from 1618 years ages. Similarly, 48% early married motherhad suffered from bleeding after delivery, 22%anemia, 19% weakness and 115 others problems
found about early marriage mothers This topic
supports to reflect the severe effects of lack of
education discrimination upon them due to forced
marriage.
Dhital (2007) mentioned in his report, as cited in
United Nations ESCAP(2008) that child marriage isperceived to be an established practice that has
occurred for generations in Nepal. Both religious
and cultural traditions have favored the marriage ofdaughters from even less than ten years of age orvery early after menarche (first menstrual
bleeding), while husbands could be much older. The
incident of such marriages varied, with a higher
rate in the Terai region in the south. The mean ageof marriage is 15 years in the Terai and 18 years in
the hill and mountain districts and the Kathmandu
valley.
Age specific fertility rate for adolescents aged 1519 has declined in the last five years (from 2006)by 10%, however the figures are still highcompared to other developing countries. This issue
is almost twice as common in rural areas than inurban areas (NDHS, 2011).. UNICEF and USAIDS(2001) says one in five male and one in ten female
early married persons have experienced sex inadolescence. This may lead to early unwanted
pregnancy. Being pregnant at young age may haveits risk. Apart from that, the culture may consider
sex at a young age without marriage as undesirable
behavior. This may hinder them to seek health careand family planning (FP) services.
Acharya (2009) carried out research in three
districts, and reported 20% adolescents being
sexually active and 16% having multiple partners.
Similarly, a study among college students in
Kathmandu showed nearly 40% adolescents were
engaging in premarital sex. The facts mentioned
above are the key entry points for this research.
Because these are the same determinants of earlymarriage in that community in Jhirubas of Palpa
district (Dahal, 2016).
Coming to intervention and achievement of Nepal,
Millennium Development Goals (MDGs) permit
unwrapped new paths for the execution of SDGs
planned for 2016-2030. The access to the quality
reproductive health care services, male dominanceEubios Journal of Asian and International Bioethics 28 (March 2018)
and lack of decisive power among females are also
the other causes behind this.
4. Methods
Early married women of Jhiribas were selected
for the purpose of this study. The total earlymarriage women of Jhuribas was 549 (derived from
Village Profile). Among them, 126 married women
were the population of the study. Participants wereselected on the basis of two criteria, such as
married women only those who got married before
20 years of age. Another criteria were those
selected married women up to 30 years with a childage between less than 3 years For the convenience
14 respondents from each ward were surveyed.
The interview schedule prepared in Nepali
language for the easiness and 10% of total
respondent (12 persons) got the trial test in
Rampur VDC Ward no 2 and 4. The questionnaire
was pre-tested for 12 married women of Rampur
VDC ward no 2 & 4 in order to reduce possible
minor error and to make practicable, simple andeasier schedule.
At first we consulted the Local Municipal Office toobtain the primary data and information about
women who married early from every ward in
Jhiribas of Palpa district. Ethical permission was
taken from the Local Municipal office. Secondary
data was derived from the concerned agencies likeas rural municipality profiles, sub-health post,
related person who take census. In this process, apilot tested structured interview questionnaire wasused.
Prior to the interview, oral consent for survey was
taken from all the participants. Almost all agreed to
be interviewed. With the assistant of 2 oriented
interviewers, necessary information were collectedfrom the participants. In addition, interviewers
reached to potential participant's home with aconvenience approach and they were asked
questioned as per designed for this study.
Interviews were carried out in September, 2017. On
average, each interview lasted for 35 minutes.
5. Socio-Economic Information of
Respondents
126 married women below 20 years of age wereselected as respondents. This study was done in therural peoples living in the Jhirubas of Palpa district.
Education is one of the main factors affecting an
individual's knowledge, attitudes and behaviors
with regard to various aspect of life, including are
at marriage. Literacy means the ability of reading
and writing. Literary is perhaps the most important
single means of social economic development.
Health statuses of family members also depend on
educational status of household head because it

57

determines to utilize the health care facilities,
decisions making of care on health.
The total literacy rate of respondents was 74%,
the remaining 26% were illiterate. Among the noneducated, only 20% were literate or can just read
and write. Similarly, 20% of the respondents hadcompleted primary level, 13% women had also
completed lower secondary level, 12% of the
women
had
completedsecondarylevel,
respectively. Only about 9% of the women were
found to have completed higher level education.
This is lower than the average for Nepal. The 2011
NDHS also shows that about 31% of women didn't
have any formal education, as compared to 26% of
illiterate (MOPH, New ERA and ICF international
Lnc, 2012).
68% of the people interviewed belong to a joint
family and 32% of people belong to nuclear family.
A small family or nuclear family can provide
sufficient facilities including nutrition, education
love and care etc so their well-being and physicalhealth will be good and joint family is opposite oftheses all facilities they are unable to fulfill all basic
needs so there are some differences in the joint andnuclear family in Nepali society.
Cultivated land is important for the people to live.
If the land is not sufficient they could not solve theirhand to mouth problem. Land belongs to eachfamily of their economic status. If they havesufficient land they can solve their problem andsafe from many health hazards, otherwise it may
add many difficulties. The responses of respondents
are presented in Table 1.
Table 1 shows that more than 71% of
respondents do have not sufficient cultivated land
to solve their land to solve their hand to mouthproblem. And it shows that the maximum
expenditure is distributed for food, health and least
for education and clothing. But only 4%
respondents have sufficient land which could feed
their families for a year.
Among all, 71% of people were found under thepoverty line in this study, there is a huge problemof lack of sufficient nutritious food supply in theirhomes, so the mother and children of the family are
suffering from malnutrition in the community,
which is an indicator for the bad health condition of
the mothers and children in this community.
Table 1: Status of Cultivated Land
Area of Cultivated landless than one Ropani
One to five Ropani
Six to Fifteen Ropani
More than one Biga
Total

N
90
20
11
5
126

Percentage
71
16
9
4
100

58

Eubios Journal of Asian and International Bioethics 28 (March 2018)

The CBS (2011) found that Nepal is largely an
agricultural country through different people
engage in different types of occupation to earn theirlivelihoods. There is a strong relationship between
occupation and early marriage and health status of
women. Most Nepalese do not have choice in theiroccupation it is determined by their parents of past
generation. The study found that almost 71%
respondents were involved in agriculture, 20% areengaged in Labor and minimum 9% are engaged inservice. More ever the table illustrates that female
respondents were more involved in traditional jobs
like agriculture and animal husbandry andhousekeeping. The majority of the respondents,
71%, were found with engaged in agriculture in thesociety, but there they do not have sufficient land so
it is very difficult to fulfill their basic needs
including foods for their family members.
Food security refers to the sufficiency of foodproduced on one's land or the adequacy,
availability and accessibility of food. A household isconsidered food secure when its dwellers do notlive in hunger, fear, or starvation (Hunt, 2009, as
cited in MOHP, New ERA and ICF international link,2012). Food security normally depends on
agricultural production in an area.
Table 4 demonstrates that food security byagricultural production in terms of its adequacy for
consumption was unsatisfactory. Only 9% of allhouseholds had sufficient food production or accessto food. In addition, 28% and 63% of all households
had enough food for only 7 to 12 months and 0-6
months respectively. These families had to depend
on sources other than their own production forsurvival.
Economic status plays an important role in family
life. Such as housing, health related problem,
education and so on solved based on their income.
The results found that 43% respondents have
below 10 thousand rupees per year income, 32% of
the respondents have 10-20 thousand yearly
income. It shows that 16% have 20 to 30 thousand
and only 9% respondents have more than 30
thousand rupees as yearly income. It is concludedin this study that most people are not able to fulfill
their fundamental needs. They are suffering from
low income and its impact in their lives is very
painful.
6. Causes of Early Marriage
Prevalence of early marriage
Age is an important factor which affects motherand children's health. If the age of mother is below
20, she is less likely to give birth to a healthy baby.
68% of respondents said their marriage age was
16-20 years, and 32% were other or below 15 years.
There is increaaed risk of disease and mortality ofthe mother and child if they got early marriage

because their organs of the body are not mature forreproduction before 20 years of their age.
A total of 126 females were married in the sample
households. Arranged marriage 62% was practiced
by 62%, though 35% were love marriages and 3%
gandharva (winning a girl by impressing her withsome performance) marriage. Study shows that the
proportion of love marriage is increasing. Most,
93% of respondents thought that modern devices
like mobiles and internet encourage early marriage.
Among them 27% responded that it applied tothem also.
Perhaps mobile phones had caused earlymarriages where love is a common form ofmarriage. Love marriage among school-going earlymarriages seems to be the trend. Study confirmedthat persons who got married early committed
suicide for various reasons, including that of earlymarriage, and that, for the reason, parents accepted
the demand of their child.
Causes of Early Marriage
Early marriage has several causes, including
social, cultural, religious, political, demographic andeconomic. In many cases, a mixture of these causes
traps children in marriage without their consent.
The responses about the causes of such marriage
are presented in Figure 1.
Figure 1 shows that most (39%) thought thatearly marriage happened because of familypressure. Another leading cause is the willingnessof child or self desire of themselves, 25%. The
analysis clearly demonstrated that early marriage
in the past occurred due to parental desires rather
than the desire of the individuals involved.
Knowledge of Early Marriage
The legal age of marriage in Nepal is 20 years forboth male and female. Marriage below 20 years iscalled early marriage. However, for this study
respondents from the age group 10-19 years weremost likely to get married before 20 of years ofduring their teen age.
Many studies have shown young girls get
pregnant before age of 18 either after marriage or
involving premature sexual intercourse. Legally theearliest marriage age of girl was 18 with consent of
parents and 20 without consent of parents
currently marriage age of both male and female is
20 as mentioned above, and has been stated incountry code (Muluki Ain) of Nepal.
Responses of the respondents about theknowledge of early marriage found 67%
respondents replied that early marriage is marriage
before 19 years of age. One third of the respondents
do not know about teenage marriage and 33% gaveEubios Journal of Asian and International Bioethics 28 (March 2018)
39%

To

of
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es
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gh
t

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ill
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rty
/
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8%

3%

pr
es
s

6%

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ily

8%

Fa
m

9%

59

Figure 1: Causes of Teenage Marriage

33%

17%
14%
9% 10%

6%

4%

2%

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2%

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ur
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ild
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Figure 2 : Knowledge of Consequences of Teenage Marriage
on Healthdifferent views about early marriage. Little
knowledge is one of the reasons of early marriage
practice. Due to the lack of knowledge and illiteracy
and the lack of improved social practices majorityof the girls on the society were found appealed toget marriage before of the age of their years, which
is not the good situation.
Knowledge about Legal Age at Marriage
According to the revised Muluki Ain, the legal ageof marriage is 20 years for male and female there isa provision of legal punishment for both couples aswell as guardian, if they marry against the law thepunishment is imprisonment of 6 months to 3 years,
or a cash payment, or both according to the case. In
order to assess the knowledge about legal
marriageable age among early married women.
They were asked about legal age at marriage. 71%
of early married respondents don't know about thelegal marriage age and only 29% know about thelegal provision. This shows that most of the
respondents do not know about the legal marriage
age. If they had the knowledge about legal marriage,
age and punishment about it, there should becontrol in early marriage practice is some extent.
Thus, there is the lack of knowledge in the
respondents about early marriage. If they had theknowledge about it, it would have played a greatrole in the restriction of early marriage practice.
Decision Making Roles in Marriage
The right to decide whom to marry and when to
marry remains with those who are getting married.
However, people think that parents (or othermembers of the family) should make the decision
for their children. Respondents who married youngwere asked who had made the decision about theirmarriages. As was analyzed above, early marriage
is considered a very bad practice by Nepali but it is
not yet prevented. An attempt was made to collectEubios Journal of Asian and International Bioethics 28 (March 2018)60

information about who had decided that the
respondents would marry young. Table 4 presents
the results of the question to identify the decision–
makers regarding the respondents early marriage.
Table 2 indicates that the father, mother or bothtook most decisions regarding marriage. Only 21%
of respondents reported that they had decided
themselves. The findings show that the paradigm
shift in decision-making from parents to children,from parental pressure to love was found. It
suggests that parental pressure is slightly
decreasing regarding marriage case.
Table 2: Major Decision -Maker Regarding Marriage
Decision Makers
FatherMotherBoth Father & Mother
Self
Friends
OthersTotal

Respondents
25
7
61
27
2
4
126

Percentage
20
6
48
21
2
3
100

Table 3: Right to make Decision of Marriage
Decision makers
Father and mother
Relatives
Self
OthersTotal

Respondents
71
9
42
4
126

Percentage
56
7
34
3
100

Right to make Decision of Marriage
The respondents were asked about who has theright to decide upon the marriages of people in thefamily. Table 3 shows that about 56% respondents
still believed that the right to make decisions abouta child's marriage lies with the father and motherand 34% said the right is that of the individual
involved. The findings showed that the power ofdecision taking by parents is declining and thedecision by self is increasing.
Consequences on Mother and Child Health
Dahal (2016) found that early marriage has
numerous adverse effects on the overall wellbeingof adolescents who are mentally, psychologically,
emotionally and physical unfit for married life.
Early marriage has led to suicide among adolescent
girls and is leading cause of death of women in
reproductive age in Nepal.
An attempt was made to find the consequences of
early marriage from different perspectives. The
respondents were asked some different questions
about the consequences of early marriage onmother and child health and their responses were
presented under different headings
Perception on Early Marriage
Early marriage is not good; it invites many
problems in mother and child health. it leads toearly pregnancy and it made both of themphysically, emotionally and intellectually weak.
Early married women lose many opportunities
including education, independence, and so on. Datashows that 71% of the women married early. They
thought that early marriage affects both motherand child; it made both of them physically,
emotionally, intellectually and economically weak.
There is high probability of death of both (motherand child) and there was loss of many opportunities
for women like education independent and otherprogress. Among them only 29% respondents felt it
good. It was good for some of them because parents
can be free from their children.
Knowledge of Consequences of Early Marriage
Early marriage forces couples to get involved insexual activity, which often ends up in earlypregnancy of the female. The health consequencesof early marriage are reported as poor maternaland child health (33%), weakness of mother (17%),
too immature for childbearing (14%), miscarriage(6%), Death of mother/ children (2%) and so on.
The analysis clearly indicates that people know thatearly marriage is harmful for immature girls inmany ways.
Reason of Miscarriage or Stillbirth
A miscarriage is the spontaneous loss of a fetus
before the 20th week of pregnancy. About 6% ofmothers had experienced miscarriage. Though thenumber of miscarriage or stillbirth is insignificant,the cause of their miscarriage or stillbirthdemonstrates the adverse consequences of earlymarriage on women's health (Table 4).
Table 4: Reason of Miscarriage or Stillbirth
ReasonHard labor and bleeding
Dependency on traditional healers
Dysmenorrheal
Lack of health institution/ equipment
Twin born
Immature mother
Position of baby
Improper care of motherHigh blood pressure
Swollen body
Fever
Evil

N=7
3
0
0
1
0
2
0
1
0
0
0
0

%
43
0
0
14
0
29
0
14
0
0
0
0

According to the American College ofObstetricians and Gynecologists (ACOG). Studies
reveal that anywhere from 10-25% of all clinicallyrecognized pregnancies will end in miscarriage.
Chemical pregnancies may account for 50-75% of all
miscarriages. This occurs when a pregnancy is lost
shortly after implantation. The woman may notrealize that she conceived.
The above findings demonstrated thatmiscarriage is obtains due to the hard work duringEubios Journal of Asian and International Bioethics 28 (March 2018)
pregnancy and which occurred due to earlymarriage. So nearly marriage can be taken as aleading factor for miscarriages.
Sexual Problem
Early marriage encourages couples to get
involved in sexual activity. Due to their physicalimmaturity, they have to face many problems.
Female respondents were asked whether they were
aware of the sexual problems and these included
lack of sexual desire 62%, painful intercourse
38% .The result clearly indicates that earlymarriage is a cause for sexual problems that candirectly effects for mother’s health.
Age of First Pregnancy
Most of the adolescent women get pregnant
before their reproductive and sexual organs
become fully developed. As a result, the rate ofmaternal and child mortality and morbidity become
high in Nepal. 71% of respondents had an age offirst pregnancy between 15-20 years and only 29%
respondents had a first pregnancy below 15 years.
The above indicators indicate that the maximum
respondents have 1st pregnancy at early age, which
enhances the high number of child birth as well as
health risk of mother and child. It is caused due tosocio-cultural tradition and due to lack of education.
Antenatal Check Up
Antenatal check up means to examine pregnant
women's health during pregnancy period. It isessential for health check up for mother and her
fetus. At least four antenatal visits are required fornormal pregnant women for safe delivery. This
study found that 80% of respondents did not get acheckup their health during pregnancy but only
20% respondents were approached to health
Table 5: Educational Status and Antenatal Check Up
Not at all
Educational Status
Illiterate
Literate
Primary
Lower Secondary
SecondaryHigher Secondary
Total

No
20
3
4
27

Per.
61
12
16
-

61

center for checkup. Most of the non-checked up
women are illiterate and due to lack of knowledge
about health checkup during pregnancy. More overthere is not availability of health checkup facilities.
Educational Status and Antenatal Check Up
Antenatal check up is an essential health checkfor mother and her fetus from conception to 28
weeks of pregnancy period, monthly checkups,
from 29 weeks up to 36 weeks and weekly check up
after 36 weeks is the period of producing baby atleast four times antenatal visits are required fornormal pregnant women for safe delivery.
Therefore, educational status of pregnant motherplays vital role on antenatal check up. So Table 5
presents the relation between educational status ofearly married mother and antenatal checkfrequency. It is evidence that 61% of illiterate
respondents had not done any antenatal check up.
Only 18% illiterate respondents had one time checkup, 12% had 2 time check up and 9% had 3 times
check up. it shows that no illiterate person hadcompleted the antenatal check up.
Among 25 literate respondents, 12% had notdone any antenatal check up, 80% had once, 8%
had 2 times check up. From the total of 126
respondents, there was only 20% (25 respondents)
who had completed the full package of antenatal
check up during their pregnancy and those were
only most educated group. Service statistics of the
fiscal year 2067/68 (NDHS report 2011) shows that
85% of the mothers received their first antenatal
care services and less than three fifths of themmade four visits indicating that more than two
fifths of the mothers did not complete therecommended four ANC visits.

Frequency of Antenatal Check Up
1 time2 time3 time4 time
Pe
Pe
Pe
No. r
No r
No r
No Per
6
18
4
12
3
9
20
80
2
8
3
12 16 64
1
4
1
4
2
13
11 69
3
19
2
13
2
13 11
73
2
17 10
83
31
24
19
25

Total
No
33
25
25
16
15
12
126

Per
100
100
100
100
100
100
-

Table 6: Economic Status and Place of Delivery
Place of Delivery
Home
CowshedHospital
Others
Total

Lack of Money
No.
Per.
9
12
22
92
4
36
35

Dependency
No.
Per.
2
3
1
4
6
37
9

Economic Status
Unemployment Difficult livelihood
No.
Per.
No.
Per.
18
24
46
61
1
4
10
63
4
36
3
28
32
50

Total
No. Per.
75 10024 10016 10011 100126

So, the status of the study area seems poor incomparison with national reports.
Place of Delivery
A significant proportion of mothers in developing
countries still deliver at home unattended byskilled health workers. Traditionally, Nepalesechildren are delivered at home either without
assistance or with the assistance of traditional birthAttendants or relatives and friends. An importantcomponent of effort to reduce the health risk ofmothers and their children is to increase theproportion of babies delivered under medical
supervision, proper medical attention, hygienic
conditions during delivery can reduce the healthrisk, complications and infections that can cause theserious illness leading to death of mother or babies.
Respondents in a survey were asked a question
about the location of delivering the baby or where
did they give birth to their child, and it was foundthat 60% reported that they have given birth totheir child at home, 19% in a cow shed, 13% in
hospital and other 9% in other places. At thenational level, only 9% of births are delivered inhealth institutions whereas 89% at home.
Due to the unsafe delivery and healthy practice,many women are suffering from RH related
problems like bleeding, infections, injury, and the
neo-natal tetanus, during the delivery; so, theyshould be safe delivered in the maternity hospital.
Condition of First Child
Really, in Nepal, the condition of children is poor.
Everyone has four children, which are often bornwith less than 2.5 kg of weight. A mother’s
nutritional status during pregnancy is important
both for the children's development and forprotecting against maternal morbidity andmortality NDHS (2012). Low pregnancy weight isgenerally associated with pregnancy outcomes e.g.
low birth weight and disability. So the question as
asked to the respondents "What was baby's
condition at birth?". It was found that 71% of thechildren had low birth weight, 2% abnormal, and
2% over weight. Only 25% reported the weight tobe normal. Healthy children represent a healthy
nation. Over 85% of the country's population is inrural areas, where many suffer from malnutritionand various disease. Size of the baby of birth andmortality are negatively associated, for example.
Children who has regarded as very small or small
have an infant mortality rate that is 60% higher
than that for average/large children NDHS (2012).
Exclusive Breast Feeding Practice
Responses to the question, "during the breast
feeding period, was your breast milk sufficient toyour baby or not?" found just more than half (52%)
said that they had not sufficient breast milk for
exclusive breast feeding practice and only 48% had
sufficient milk for exclusive breast-feeding. The

analysis clearly demonstrated that early marriage isthe main cause of breast milk sufficiency due tomaturity of reproductive organs.
Economic Consequences of early marriage
The respondents' responses with regard to aquestion about the economic consequences of earlymarriage made it evidence that the economic
consequences of early marriage are difficulty inearning a livelihood 40%, lack of money 28%,
jobless 25%, and dependency 7% respectively.
Economic status directly impacts livelihood.
Economic Status and Place of Delivery
Economic status of family plays a vital role todefine the delivery place. From Table 6 we can seethat among the 75 respondents of home delivery,
12% said it was due to lack of money, 3% due todependency, 24% due to unemployment and 61%
due to a difficult livelihood. A total of 24
respondents delivered in a cowshed, 92% due tolack of money, 4% due to dependency and 4% due
to difficult livelihood. A total of 16 respondents,
37% of dependent and 63% of employed mothersdelivered at safe maternity hospitals. Total 28
respondents delivered in other places, 36% due tolack of money, 36% due to unemployment and 28%
due to difficult livelihood.
Comparatively, this study shows that, most of thepoor economic status respondents delivered athome or in a cowshed, and few better situations'
respondents delivered at hospitals and other places.
NDHS 2011 has also shown 36% of deliveries
attended by SBA. Service statistics of the fiscal year
2067/68 shows that 37% of the mothers deliveredin health facilities, this is close to the findings of
NDHS 2011 (35%). In this study, among a total of
126 respondents, only 13% of respondents
delivered in hospitals, and this is a poorer situation
than the national average.
7. Discussion
The objectives of this study were to examine thecauses of early marriage and assess theconsequences on Maternal and Child health. Major
findings are presented below.
Socio-Economic Information
1. It was found 32% among female respondents
married at the age below than 15 years and 68%
married at 16-20 years. So early marriage is stillprevalent.
2. 26% respondents are still illiterate, only 20%
have completed secondary level education.
3. 71% respondents depend on agriculture and 20%
depend on Labor, and 9% depend on service.
4. 69% people belong to a joint family and only 32%
are in a nuclear family.
5. 71% respondents have not sufficient cultivatedland, only 4% have sufficient cultivated land.

Eubios Journal of Asian and International Bioethics 28 (March 2018)
Causes of Early Marriage
1. In the age group of 16-20 years, the average
prevalence of early marriage among respondents
was 68%.
2. Arranged marriage was practiced among 62%
and love marriage by 35%.
3. Data from respondents who married early
revealed that 39% of early marriage occurredbecause of family pressure. Another leading cause
was self desire. The finding revealed that children
themselves like to take part in "love marriages" atan early age due to mobile phones and mass
media promoting “love”.
4. Their family pressure, self-desire (falling in Love),household activities, poverty, tradition, and lackof education are the main causes of earlymarriage.
5. 33% of the early married women do not haveknowledge about early marriage.
6. More than 71% did not know the legal age ofmarriage. Their ignorance may be one reason
early marriage prevails.
7. Out of total respondents, for 48% of respondents'
both father and mother were major decision
makers, and 21% of respondents had self
decision.
8. 56% respondents still believed that the right tomake decisions about a child's marriage lies withfather and mother and 34% said the right is thatof the individual involved.
Consequences on Child and Mother Well being
1. Out of total respondents, 71% of the women
married early.
2. Respondents who had married early were mostly
aware
of
the
physicalhealth-relatedconsequences of early marriage. All 3 child deaths
occurred among them. One third, 33%, had
experience of poor maternal and child well being,
17% experienced weakness, 14% were immature
for child bearing, 10% had uterine prolapse
problems, 9% experienced lower abdomen pain,
6% mentioned a miscarriage, 4% mentioned
bleeding from vagina, 2% mentioned a menstrual
problem, and 1% mentioned cancer and mental
problems, respectively.
3. Out of 6 persons with miscarriage problem, 43%
said that they experienced hard labor andbleeding, 29% said it was being an immature
mother, 14% said it was improper care of mother,and 14% said there was a lack of healthequipment.
4. Regarding sexual problem, 62% had experienced
loss of sexual desire and 38% had experienced
painful intercourse.
5. Out of total, 71% got their first pregnancy
between the age of 15-20 years.

63

6. Out of total respondents, 20% were approached
to prenatal check up.
7. More than half, 59%, children delivered at home,
19% in a cowshed, 13% were at hospital, and 9%
children delivered at other places.
8. Out of total, only 25% found the newborn within
the normal range when birth had occurred. 71%
of the newborns were of low birth weight, 2%
were abnormal and 2% overweight.
9. Out of total, 67% of the respondents were notfeeding colostrum and only 33% of the
respondents feed colostrum to the newborn baby.
10. Out of total, 48% had practiced exclusive
breast-feeding due to sufficiency of milk and 52%
practiced inclusive breast-feeding and formuladue to insufficiency of milk.
11. The economic consequences of early marriage
are found to persist with 40% saying they had adifficult livelihood, 28% a lack of money, 25%
were jobless, and 7% dependency. So poor
economic status directly affects persons for adifficult livelihood and it results negatively on themother and child’s health.
8. Conclusions
Educational and economic status of early married
women is not satisfactory. The majority of the earlymarried women are engaged in household work.
Agriculture and labor are the main occupations, sothey are suffering from low income and its impact
in their lives is very painful. Most people live under
the poverty line (Less than 1 Ropani Land = 508m2),
which is a huge problem because of lack ofsufficient nutritional food supply in their homes
which is an indicator for bad well-being conditionof the mother and her child.
Early marriage is still prevailing in the Jhirubas
VDC where early marriages used to occur becauseof parental pressure but it is now less significant
than falling in love early, and fulfillment of sexualdesire. Mobile phones and mass media havecontributed to greater early love marriages among
recent early married women’. Most of the
respondents have no idea about legal marriage age
and punishment about it. If they had the knowledge
about it, it would have played a great role in the
restriction of early marriage practice.
Most of the respondents were aware of thephysical health-related consequences of earlymarriage. They suffered from different physicalhealth-related problems, for example, poormaternal and child well-being, weakness,
immaturity, miscarriage, sexual problem, no prenatal check and so on. Most of the poor economic
status respondents delivered at home and in a
cowshed with assistance of family members andFemale Community Health Volunteers. A few better
situated respondents delivered at hospitals and64

Eubios Journal of Asian and International Bioethics 28 (March 2018)

other places. Most of the respondent's babies did
not get exclusive breast-feeding practice. Most of
the children are suffering from low birth weightand inclusive breast-feeding practice.
After considering all of the findings and the study
indicated that early marriage is mainly affected bytraditional system (family pressure) and towards
marriage practices, socio-economic status, lack of
education, low knowledge about marriage and legal
age at marriage are also act as effecting factors forearly marriage practice.
9. Recommendations
Early marriage has numerous adverse effects on
the overall wellbeing that are mentally,
psychologically, emotionally and physically unfit for
married life. It is globally accepted as a problem,
which deprives especially girls of education andhealth services, the chance to learn skills anddevelop their personalities. So based on the abovefindings
andconclusions
thefollowingrecommendations are made.
Policy level:
1. Forceful legal action can have many harmful
results in the lives of couples who marry young.
Instead, educational motivations can work.
Therefore, programs should be focused to enroll
and retain girls in schools.
2. Ending early marriage requires the consolidated
efforts of government and other organization.
Therefore networks, the coordination andcollaboration of different stakeholders, andorganizations from community to national levelshould be strengthened.
3. The massive awareness about increased legal age
from 18 to 20 years should be done, and laws
should be strictly implemented protecting rights
of victims.
4. Ending early marriage should be established as acrosscutting issue and mainstreamed into all
development works and mainstream into local
policy of federal government and activities andeffectiveness of activities focusing reducing earlymarriage should be done in collaboration with
NGOs/INGOs
Therefore,
developments
organizations' (NGO/ INGOs) activities will be
implemented through an integrated approach.
Practice level:
1. Early marriage is still widely prevalent incommunities. So in order for early marriage
livelihood opportunities and income generation
support opportunities should be made available
in the concerned community.
2. Adolescent boys and girls should be empowered
to manage their sexual and reproductive healthissues through different approaches such as peer

education, comprehensive sexuality education,and life skill based education in school.
3. Child Club, Youth Club and Local groups should
be mobilized and engaged massively to address
the issues and combat early marriage hence todiscourage to both parents and adolescents tomake get married in early age.
4. All educational institutions, government agencies,
should focus on creating social pressure andaction should be taken with those who are willingto marry their young children below 20 years andeducate the young people regarding advantage ofgetting married after 20 years also informing
them on about essentials of delaying pregnancy
and adopting safe sexual practices as a way of life.
5. Well-being and health services and linkage toprimary health services should be madeaccessible. So that they can utilize the existing
health services as they need to.
6. Non-formal education also would be a better
option to eradicate backwardness/ illiteracy ofconcern community.
7. Existing community and school based complaint
hearing structure should be strengthened andthough teachers and, community members andlocal stakeholders/’ parents and children should
be made aware about legal and healthconsequences.
Further ResearchThis study can be used as a reference for further
research, especially:
1. A similar study can be conducted on a larger scale
so that the generalizations can be made to thewider population.
2. This study is mainly focused on the health relatedconsequences of early marriage women and herchild. Therefore, further research on broader
aspects including Social, Economic, Educational,
Psychological and other consequences that can begeneralized for national reference, should be
conducted.
3. Similar studies can be conducted to find out about
early marriage and maternal/ child health among
different communities of the country.
10. Bibliography

Acharya. (2009). Sexual Habit among Adolescents. Unpublished
Master degree Thesis
Aryal. (1995). Affecting factors for fertility on Tharu Communityof Bardiya. Tribhuvan University, Kirtipur: Unpublished
Master Degree Thesis.
Bayisenge, J. (2010). Early Marriage as a Barrier to Girl's
Education:A Developmental Challenge in Africa. Online
Available (National Universityof Rwanda)
Bhandari, K. (2000). Study on Safe Motherhood Practice on
Kumal Community of Gulmi District. Unpublished Master's
Degree Thesis, Tribhuvan University,Kirtipur.
CBS. (2011). National Reports, an analysis of situation of Nepal.
Cheetry. (1993). Marriage system in patriachal society of Jhapa
District. Unpublished Master Degree Thesis.

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Dipya. (1992). Low birth weight and cild morbidity andmortality. Kathmandu Nepal: Safemotherhood project .
Ghimire, B. (2001). Effects of Early Marriage on Women's Healthin Damin Community of Bhoretar VDC of Lamgung. Tribhuvan
University, Kirtipur: Unpublished Master's Degree thesis.
Gubhaju, B. (2002). Adolescent reproductive health in Asia.
Asia Pacific Population Journal, 97-199.
Indira. (2004). Affecting factors of low birth weight babis among
Early mothers in Koshi Zone Hospital Morang. Unpublished
Master Degree Thesis.
Karki, A. K. (2060). Foundation of Population Education andReproductive Health.
Mahara, D. K. (2006). Helath Problem of Early Marriage Practice,
A study on Khalanga VDC, Darchula District. Tribhuvan
University, Kirtipur: Unpublished Master Degree Thesis.
MoH. (2011). Nepal Demographic and Health Survey.
Kathmandu.
Ministry of Health (MoH), Nepal; New ERA; and ICF. 2017.
Nepal Demographic and Health Survey 2016. Kathmandu,
Nepal: Ministry of Health, Nepal.
Muluki Ain. (2064, New Revisions, Mahal 17, Behabariko 221).
(2064, New revision). Muluki Ain Civil Act. Nepal Government.
Dahal G (2016) Childhood Marriage: A Challenge to Achieve
SDGs in Nepal. MOJ Women’s Health 2(3): 00034. DOI:
10.15406/mojwh.2016.02.00034
Park, J. A. (2003). Textbook of Prevention and Social
Medicine,14th edition.
Pokhrel, Nita. (1984). A study of the Age at Marriage, theReasons for Marriage at Different Ages, the Age at First Birthand Pregnancy outcomes. Rectors office.
Save the Children (2012). Child Marriage in Nepal, Research
Report. Plan Nepal. www.savethechildren.org
Shah, N. (2004). Early Marriage and Its Effects on Maternal andChild Healthcare of Kurmy Community in Udayapur VDC,
Banke District. Tribhuvan University, Kirtipur: Unpublished
Master's Degree Thesis.
Shakya.(1997). Affecting factors for delayed pregnency.
Unpublished Master degree Thesis.
Shrestha, A. (2012). Early Pregnancy in Nepal: Consequences,
Causes and Policy Recommendations. KIT (Royal Tropical
Institute)/Vrije Universiteit Amsterdam,The Netherlands:
Unpublished Master's Degree Thesis in M.PH.
Shrestha, I. (2000). A Study on Affecting Factors of Low Birth
Weight Babies Among Early Mother,. Maharajgung:Unpublished Thesis, Tribhuvan University, Institute ofMedicine Nursing Campus .
Subedi, P. (2001). Early Pregnancy and It's Effect on Child andMother's Health in Chepang Community of Dhading Distict.
Tribhuvan University, Kirtipur: Unpublished Master Degree
Thesis.
Tristam, P. (2011). Child Marriage : Facts, Causes, andConsequences, Discrimination, Sexual Abuse, Trafficking andRepression.
Online(Available
from.http://middleeast.about.com/od/humanrightsdemocra
cy/a/childbrides.htm(Accessed April2012).
Tuladhar, S. (1997). A study on the Knowledge Attitude andPractice of Early Mothers on Reproductive Health Regarding
Pregnancy. Maharajgung: Unpublished Master Degree Thesis,
Tribhuvan University Institute of Medicine Nursing Campus.
UNICEF. (2001). Reproductive Health during Conflict and
Displacement a Guide for Program Managers;. WHO,
Department of Health and Research.
UNICEF. (2011). The state of the World's Children 2011. New
York: UNICEF. www.unicef.org
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USAID. (2007). New insights on Preventing Child Marriage, A
Global Ananlysis of Factors and Programs. ICRW.
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Wolff, H. a. (2005). Social Science Research and Thesis Writing,
4th edition. Kathmandu: Buddha Academic Enterprises
Pvt.Ltd.

65

Prevalence of Oral and Dental
Diseases and Oral Hygiene Practices
among Illicit Drug Abusers- Prof. Dr. Md. Anower Hussain Mian, DDS, MPH, PhD,
Prof. and Head, Dept. of Community Dentistry, Faculty of
Public Health, Bangladesh University of Health Sciences,
Mirpur-1, Dhaka, Bangladesh
Email: ayonshafi@hotmail.com- Dr. Kazi Md. Sakib Hossain, MPH,
Lecturer, Dept. of Community Dentistry, Faculty of Public
Health, BUHS, Mirpur-1, Dhaka, Bangladesh
Email: kms_doc@buhs.ac.bd- Dr. Nasrin Akhter, PhD,
Senior Lecturer, Dept. of Pharmaceutical Sciences,
Faculty of Life Sciences, North South University, Dhaka,Bangladesh
Email: luckyayon@hotmail.com- Darryl Macer, Ph.D., Hon.D., MPH
President, American University of Sovereign Nations,Arizona, USA
Email: provost@ausn.info

Abstract
There has been increasing incidence of addiction
to certain illicit drugs amongst people belonging tovarious strata of society, particularly among young
people in Bangladesh, as well as in westerncountries. Drug abuse results in several directconsequences including multiple physical andmental problems such as cardiac crisis, respiratory
depression, liver cirrhosis, nephropathy, infectious
diseases such as hepatitis, AIDS, and tuberculosis,
injury-associated disability, mental disorders suchas depression, and oral health problems. This is thefirst published study of illicit drugs abusers’ healthrelated data in Bangladesh. The present study was
conducted to evaluate the prevalence of oro-dental
diseases and explore attitudes towards oral hygiene
practices among a group of illicit drug abusers sothat required interventions can be planned for thegood health of those who are in addicts with illicit
drugs in this region. This study was comprised of
120 drug addicts admitted in a drug rehabilitation
centre in Dhaka, Bangladesh. Most of theparticipants were involved in abuse of more than
one drug and the most abused drugs were heroin(55%),
cannabis(ganja)(43%)
andmethamphetamine (yaba) (31%). Oral hygiene
practices of the drug users were alarming where
78% clean their teeth in wrong way(once/three/more than three times a day) and 23%
clean their teeth in right way that is two times daily
but 74% of them never used any mouth washes. On
the other hand 92% respondents didn’t use any
dental floss to maintain oral hygiene properly. The
schedule of dental check-up was also poor, only

66

Eubios Journal of Asian and International Bioethics 28 (March 2018)

37% respondents visited a dentist once in a year.
Ignorance about oral health (48%), money-fear(32%) and money-bad experience (25%) are the
obstacles for the respondents to visiting a dentist.
Presence of carious teeth was seen in all persons(100%), while bleeding gum, shallow pockets anddeep pockets were found in 42%, 44% and 12% of
drug users, respectively as in CPI index. Symptoms
of xerostomia (mostly in heroin abusers) and methmouth (mostly in yaba abusers) were found in 18%
and 8%, respectively. Premalignant states ofleukoplakia were diagnosed in 8% of drug users.
Chi squared test was applied wherever applicable.
Significant relationship with oral health condition(at the level of significance at p<0.05) was foundwith age group, marital status, types (heroin, yaba
and cannabis) and duration of drug abuse. Drugabuse is detrimental to oral health, so abusers need
to be more aware of the dangerous effects of drugs.
1. Substance Abuse
Substance abuse' is a disorder characterized byrepetitive drug use that results in social or
economic distress and is often associated withmedical problems. 'Drug addiction' is a chronic,
relapsing disorder characterized by compulsion totake a drug and loss of self-control in limiting drug
intake (Braunwald et al., 2003). The substances ordrugs may be natural or synthetic, but is somethingthat has a psychoactive effect and alters or modifies
the functions of a living organism. Globally, thenumber of drug abusers in 2007 was 200 million,
i.e. 4.8% of the global population (World Drug
Report 2007).
Drugs commonly abused are narcotics(including poppy, opium, morphine, codeine, heroin,
opioids, meperidine, pethidine, and methadone),cannabis (marijuana, hashish, and dried parts ofcannabis plant), stimulants (amphetamines,
cocaine), hallucinogens (LSD, phencyclidine,
mescaline,
andpsilocybin),
depressants(barbiturates
andbenzodiazepines),
andmiscellaneous (antihistaminics, solvents in aerosols,
glue, and whitening fluid) (World Drug Report1997).
Medical complications of drug use that are
relevant to dentistry include abscesses at injection
sites, viral hepatitis, Human Immunodeficiency
Virus, endocarditis and anaesthesia complications(Meechan, 1999). Studies have shown that thedental health and oral health are affected by drug
abuse (Porter et al., 2005, Robinson et al., 2005).
Drugs abused adversely affect the oral soft andhard tissues (dental caries, periodontitis) or may
lead to potentially malignant states (leukoplakia,
oral submucous fibrosis) or may predispose to oral
infections (candidiasis, gingivitis) by compromisinglocal immunity (Thavarajah et al., 2006).

The oral health of drugs abusers has received
less attention. There are case reports of specificoral changes although epidemiological researchshows these changes to be uncommon (Du, 2011).
High caries experience is seen in heroin users,
perhaps caused by a combination of xerostomia
caused by opiates and the high sugar content of oral
methadone solutions used to manage withdrawal
from the drug (Du et al., 2011, Angelillo et al., 1991).
Oral cleanliness may also be reduced in opiate
users (Molendijk et al., 1996). Oral effects ofcocaine are related to administration of the drug via
nasal inhalation, smoking and direct smearing on
the oral mucosa, especially the gingivae (Parry,
1996). Cocaine has a vasoconstrictive effect thatcauses ulceration and atrophy of the tissues. There
may also be stimulant effects on the facial andmasticatory muscles.
Drug users may also have special needs inrelation to receiving dental care. Anecdotally, they
may be dentally anxious and have low pain
tolerance requiring careful pain relief and a good
rapport with the dentist (Sainsbury, 1999). They
are unable to assess their dental need and therefore
reluctant to go for a dental treatment (Sheridan etal 2001). Similar difficulties have been noted inother areas of healthcare. Drug users experiencemarginalization and avoidance by service providers
and perceive services to be unavailable (Ortiz et al1997).
2. Drug abuse in the Bangladesh Context
Drug abuse is a direct threat to the economy andsocial aspects of a country. In Bangladesh, it is anational crisis growing every day. People ofdifferent age groups, although especially ranging
from 18 to 30 years of age, of different professions
and of different social status are abusing drugs.
There are millions of drug-addicted people in
Bangladesh. The rapid increase rate of drug addicts
reported in recent epidemiological surveys carriedon the three divisions of Bangladesh reflected that
this country would very soon turn to a potential
venue of drug abuse. Increased criminal activities
like hijacking, extortion etc. to collect money forpurchasing drugs destroys social security andpeace. Immediate stoppage of illicit drugtransportation into and within this country isessential to save our population and country fromthis deadly game (Shazzad et al. 2013).
Recreational drug abuse eventually limits thenormal activities of life through leading to themalfunctioning different vital organs including
heart, kidney, brain, liver and bone as well. In a
short time of starting abuse, tolerance developed
from the most abused drugs and results inincreasing dose. Common features associated withdrug abuse include lack of patience, sleep

Eubios Journal of Asian and International Bioethics 28 (March 2018)
disturbance, confusion, head-ache, feeling dizzinessduring interval of taking drugs, hallucination,
purturbance, lethargy, sexual abnormality, violence,
abolished humanity and judgment, and indisciplinein personal life (Leshner 1997).
Bangladesh is situated in the central point
between the ‘golden triangle’ (Myanmar, Thailandand Laos) and the ‘golden crescent’ (Pakistan,
Afghanistan and Iran) in terms of geographicallocation. Bangladesh with its easy land, sea and airaccess is becoming a major transit point. Traffickers
who supply drugs to the markets of North America,
Africa, and Europe are routing their shipments
through Dhaka, Chittagong, Comilla, Khulna, andother routes in Bangladesh. It is believed that with
the increasing quantity of the wares more and more
people are likely to get involved in drug business. In
this way it ultimately contributes to increasing thenumber of drug abusers in the country as well. To
procure money for buying drugs, addict makes
himself associated with different criminal groups
and commit crimes (Simpson et al., 2010). In astatistical study it was shown that among a study of
253 drug abusers in Bangladesh, 31% wereaddicted to cannabis, 26% to alcohol, 24% tophensidyl, 10% to heroin and 9% to diazepam,
antihistamine, etc. The male: female ratio was 20:1.
The predominant age groups are: 5% between 1015 yrs, 58% between 18-35 yrs, 20% between 3550 yrs and rest were above 50 yrs of age (Shamim
et al., 2005).
Despite there being data available in related tothe prevalence of oral health of drug abusers
worldwide but no study has been performed in
Bangladesh on the geographical disparity, types ofdrugs, pattern of used, duration of used,environment and physiology (race) and so on.
Evaluation of the prevalence of oral health ofdrug abusers is important on many fronts:
Bangladesh is a developing country where disease
burden is enormous and availability of curative
treatment is quite inadequate compared to what isneeded. Prevention is better than cure. But data
related to overall oral health status of drug abusers
is insufficient in our country, clinician’s awarenesslevel about oral health is very low, thus the present
study was conducted to (1) examine the prevalenceof oral health status; and (2) estimate common oral
health practices among drug abusers in selectedrehabilitation centers in Bangladesh. It may provide
information on the underlying pathologicalprocesses, signs and symptoms of oral diseases
associated with drug abuse. This may help
clinicians to identify such drug abusers frompatient reported symptoms and thus facilitate morecomprehensive and multidisciplinary prevention
approach to the management of addictions.

67

3. Effects of drug abuse on different vital organs
Over the past decade drug addiction has been
considered as a brain disease. Structural andfunctional changes of the brain due to repeated useof addictive drugs can persist after even stoppingthem. When the brain becomes adapted withdifferent changed chemical and physiologicalconditions, addiction takes place (Leshner, 1997).
Addiction, started with progressive increase of drug
intake, manifests as a circuit of malfunctioning of
brain with compulsion of taking it which ends withloss of control on taking it (Koob, 1997).
Drugs that are abused for achieving pleasantsensation mostly act on neurotransmitters. Many of
those increase dopamine release and cause
persistent nerve stimulation which gives energetic
and euphoric effects. This chronic and uncontrolled
stimulation causes damage to nerve terminals.
Studies with methamphetamine neurotoxicity
proposed that this drug causes excitotoxicity toneuron.
Onemechanism
explainedthat
methamphetamine
binds
with
dopaminetransporter, enters into presynaptic nerve terminal
and force dopamine to be released from vesicles.
Thus increases dopamine and serotoninconcentration in synaptic cleft. Another mechanism
included that methamphetamine decreases
dopamine reuptake by reducing activity of
dopamine transporter and thus causes persistentnerve stimulation which ends in nerve damage.
Free radical mediated apoptosis of nerve cell alsosuggested as pathway of methamphetamine
induced neurotoxicity (Nicole et al., 2011).
Amphetamine and its derivatives, reported as
cardiotoxic drugs, manifest their toxic effects byincreased heart rate, hypertension, cardiac
myopathy, cardiac necrosis or myocardial
infarction, cardiac arrhythmia or cardiac failure etc.
Left ventricular hypertrophy mediated by oxidative
stress from methamphetamine abuse wasdescribed by a separate study (Jacobs W, 2006).
These drugs commonly induce hyperthermia(Kevin et al., 2010).
Stimulant induced cardiotoxicity commenceswith excessive activity of catecholamines.
Persistentreleaseof
dopaminebymethamphetamine abuse increases heart muscle
contraction and heart rate. Additionally,catecholamine toxicity produces fibrous tissue andincreases the size of heart muscle cells. Study withacuteorchronic
administrationofmethamphetamine suggested its cardiotoxicity
induction.
Acutecardiotoxicityofmethamphetamine marked with acute myocardial
infarction and sudden cardiac death whereas
chronic cardiotoxicity with development ofcoronary artery disease and cardiac myopathy(Kaye S, 2010). However, several clinical68

Eubios Journal of Asian and International Bioethics 28 (March 2018)consequences resulted in cardiomyopathy withdegraded cardiac mitochondria, extreme myofibril
contraction
andlost
myofilament.
Methamphetamine treated rats, diagnosed withmyocytic degeneration and necrosis in heart,developed myocardial damage with sign ofmyocytolysis, contraction bands, atrophied
myocytes, and spotty fibrosis (He et al., 1996).
Being the major site of excretion, kidneys are
frequently victimized by drugs or their toxic
biotransformed products either directly or
indirectly. Amphetamine derivative especiallymethamphetamine
reportedtoinducerhabdomyolysis with flow of massive toxins
through kidney causing it to shut down. Anothermechanism of kidney failure by the stimulant drug
described as increased heart rate and contraction ofblood vessel which cut off blood flow to the kidney(Tokunaga et al., 2006).
Renal damage and peroxidative injury observedin rat kidney after acute and sub-acuteadministrationofmethamphetamineinimmunohistochemical study in a separate
investigation. Blood test revealed significant
increaseincreatinineandcreatinine
phosphokinase and decrease in K, Ca & P
suggesting renal tubule damage by repeatedadministration of methamphetamine (Tokunaga etal., 2006).
Bone remodeling is oriented by the co-ordinatedactivities of osteoblast, osteocyte, osteoclast andbone lining cells continues to maintain good bonequality. The quantity of mineralized bone and bone
per unit volume, known as bone mass and bonedensity respectively, represent bone quality.
Inherited factors and environmental influencessuch as pathology, nutrition and drug use influencebone remodeling. However, exact reason of drug
induced disruption of bone remodeling stillrequires thorough investigation. Some evidence
suggested that drug induced bone defect might
result from inhibition of growth of trabecular boneby increasing urinary excretion of calcium (in caseof caffeine) or direct toxicity to osteoblast cells(alcohol).
Drug induced bone toxicity frequently
manifested as: osteomyelitis or bone infectiongenerated usually from intravenous drug abuseusing dirty needles and contaminated drugs;
osteoporosis- caused by the malnutrition seen in
long-term stimulant users; osteopenia or reducedbone density- created usually from opiate
addiction; temporomandibular joint disorder (TMJ),
dental damage and decay- associated withstimulant abuse probably due to habitual teethgrinding
duringstimulation
andstress.
Malnutrition among drug abusers causes poor joint
health and arthritis. The poor postural habit ofabusers also affects their spinal health causing
weakening of spine’s supporting muscles andincreasing risk of spinal injury (Drug & Alcohol
Rehab Florida, 2013).
Several studies suggest methamphetamine
abuse exerts negative effects on bone. The strengthof the calcaneus bone determined by ultrasoundbone densitometer and broadband ultrasoundattenuation found significantly lower among
methamphetamine abusers as compared to control(Katsuragawa, 1999). In a separate study,
methamphetamine decreased bone density inlumbar spine among its abusers (Kim et al., 2009).
Mouth dryness of methamphetamine abusers
induced tooth decay by reducing the protective
action of saliva.
However, methamphetamine toxicity in mice isexpressed in different ways as in human abusers.
Researchers found increased osteoblast anddecreased osteoclast activity in mice after longterm treatment with methamphetamine resulted inincreased bone formation (Tomita et al., 2015).
Low levels of Vitamin K associated with low rates ofbone turnover increased risk of osteoporosis.
Drug induced hepatotoxicity comprises about
10% of all types of acute hepatitis (Zimmerman,
2000). The liver’s position between drug
absorption site and systemic passage and moreover
its metabolic role favours the drugs or toxic
metabolites to attack it very easily as compared toother target organs (Russmann et al., 2009). Fourmost important highly specialized cells and vessels
constitute liver. The majority of liver tissue iscomposed of parenchymal cells known as
hepatocytes which are the main site of metabolic
activitis such as various biochemical reactions
regarding synthesis and breakdown of essential
biomolecules, necessary for normal body activities.
Hepatocytes work in separate groups to perform
multiple functions included repairing of the injured
liver by rapid regeneration and biotransformationof the harmful entities. Rest of the cells of livertissue or non parenchimal cells are kupffer cells,
stellate cells and liver sinusoidal cells whichfunction as defender from harmful bacteria andantigens, store vitamin A and control the passage ofnutrients and important molecules from bloodvessel into liver. Hepatic stellate cells additionallycontribute to liver regeneration and formation offibrosis and tumor as well (Remmer, 1999).
Liver, by itself, produces the necessary enzymes
for metabolism or biotransformation of nutrients or
xenobiotics making those suitable for used by body,stored or eliminated as whatever needed.
4. Justification of the study
Drug abuse, one of the world’s most devastating
health problems (Nessa et al., 2008) may also beEubios Journal of Asian and International Bioethics 28 (March 2018)69

considered a prevalent problem, because, forexample, in 2009 between 149 and 272 million 15to 64-year-olds around the world reported using
illegal drugs at least once during one year (United
Nations Office on Drug and Crime, 2011).
Over the past two decades, it has also beenrecognized that tobacco and drug abuse isassociated with oral diseases. However, for otherforms of oral diseases, the prevailing opinion formany years was that if drug users did have more
oro-dental diseases, it was probably due toneglected oral hygiene practices. Taking the drug
abusers as a study population this study will
explain in which extend this section of people isvulnerable to the oral health related diseases. The
gathered information by the current study will add
to the data bank on issues related to drug abuses in
Bangladesh.
Keeping this in mind we conducted an
exploratory pilot study to evaluate dental diseaseprevalence and patterns, and assess the knowledge
and attitude towards oral hygiene practice of drug
abusers. The results of this present study
emphasize a need for special attention fromgovernment sector and other health organizations
to meet the basic oral health needs of thiscommunity according to the prevalence of dental
diseases among them. Also oral health careprograms should be organized for addicted persons
in order to educate them regarding proper oral
hygiene practices.
The scantity of information on the drug relatedoral health problems among the Bangladeshi
population has been found in the publishedliterature. Therefore, the present study will also
make an effort to assess the adverse effects of drugs
abuse on oral health which could be helpful topolicy makers to identify the information gaps andformulate guidelines to solve this health problem.
It is expected that the result of this study will
influence our national health policy and emphasis
will be given on educational program among drug
abusers and in future it will ultimately help toreduce the disease of the oral cavity due to drug
abused. The result of this study could also be used
as a baseline for future study.

• To study the oral hygiene related practices andattitudes towards oral health.
• To find out the association between oral healthstatuses, types of drugs and socio-demographic
features among the study population.
The independent variables in this study were:
Age, Sex, Education of participant, Occupation of
the participant, Marital status of the participant,Types of drugs abused, Duration of abused drugs
and Oral Hygiene practices. The dependent variable
was Oro-Dental diseases.

5. Methods
Objectives
The key research question is what is theprevalence of Oral-Dental Diseases and attitudes
towards the Oral hygiene practices among illicit
drug abusers? The general objective is to assess theprevalence of oro-dental diseases among the illicit
drug abusers and their attitudes towards oral
hygiene practices. Specific objectives include:• To assess the prevalence of oro-dental diseases
among illicit drug abusers.

A. Xerostmia
Xerostomia also termed dry mouth (Scully et al., 2008)as a symptom, which may be associated with a change inthe composition of saliva, or reduced salivary flow
(hyposalivation).
B. Leukoplakia
Normally refers to a condition where areasof keratosis appear as firmly attached white patches on
the mucous membranes of the oral cavity and whichhave a risk of malignant transformation (Neville BW etal.,2002
C. Lichen Planus

Operational Definitions

Oral Hygiene Practice: This is the way of practicing
regular oral and dental care which includes-proper teeth
cleaning by tooth brush and tooth paste after breakfast
and before going to bed at night, regular visit to dental
health care personnel at minimum 6 months interval.
Regular use of dental floss and mouth wash is also an
important part of oral hygiene practice.
Gum disease (periodontal disease): Infection or
inflammation of the surround the tooth is known as gum
disease. Depending on the severity, gum disease isgenerally divided into two type- gingivitis andperiodontits. Gingivitis means inflammation of the gum.
Periodontitis occurs if gingivitis is left untreated. It
becomes worse and progresses to involve the tissue thatjoint the teeth to the gum (the periodontal membrane)
which is characterized by the gum inflammation, withredness and bleeding, deep pocket (greater than 3 mm indepth) formed between the gum and the tooth.
Pocket depth: Increased in the depth of gingival sulcus
and forms the dental pocket. Naturally the sulcus depth
is 1-2 mm. It is measured from the cementoenamel
junction to the deepest point of the pocket.
DMFT: This is the method of assessing decayed/caries,
missing, filling teeth of adult permanent teeth. Mouth
mirror and explore or caries probe are used to examine
all teeth except 8s.
CPI –INDEX: Severity and degree of periodontal
diseases (gingivitis, periodontitis) in an individual (or ina section of a population) are assessed by CPI index.
Scoring: The scoring criteria are:0: No periodontal disease.
1: Bleeding on probing (mild periodontitis)
2: Calculus with plaque seen or felt by probing(moderate periodontitis).
3: Pathological pocket 4 – 5 mm and more (severe
periodontitis)

Mucosal (Oral) lesions:

70

Eubios Journal of Asian and International Bioethics 28 (March 2018)

Lichen planus (LP) is a chronic inflammatory disease of
the skin and mucous membranes (Greenberg MS et al.,2008
D. Meth mouth:
Methamphetamine abusers show bruxism, excessive
tooth wear, xerostomia, and rampant caries (so-called
meth mouth) (Morio KA et al., 208): a condition
described by patients as "blackened, stained, rotting,crumbling or falling apart" (Saini T et al., 2005).

Study Design

In Bangladesh there are no precise figures of thenumber of drug dependent people, but it is estimatedthat around 4.0 million people are dependent on someform of drugs, and the increasing trend among all kindsof people are alarming. Comparing to this situation
there are still very few treatment and rehabilitation
facilities in the country. However, the study populationsof illicit drug abusers were enrolled from drug
treatment and rehabilitation center admitted fortreatment of drug dependence.
Identifying drug abusers in the population can bedifficult with co-operation and compliance being
additional problems. This is overcome by recruiting
subjects from drug rehabilitation centers purposively.
This study was conducted from December 2016 to
May 2017. The population of the study comprised drug
abusers who are attending for treatment of drug
dependence in rehabilitation centre. The inclusion
criteria was persons who are/were using any illicit
drugs and are presently undergoing treatment for drug
dependence at a rehabilitation center were included in
the study. Exclusion criteria were positive for HCV, HBV
and HIV (exclude them by their previous record book);
and dependent on tobacco and alcohol alone.
For the clinical examination, a modified WHO
assessment form (1997) was used. A semi-structured
questionnaire translated into Bengali language wasadministered. The questionnaire consisted of (1) sociodemographic
factors(age,
education,andoccupation/profession); (2) history of drugs abused
assessed were types of drug); (3) oral health habits(tooth brushing, other oral hygiene aids, and dental
visits); (4) Open question- to assess their attitudes
towards oral hygiene, dental treatment and overall
health and (5) assessed prevalence of oro-dental
diseases by the WHO Oral Health Assessment Form
(1997) Modified. Data was collected in two ways using
both a semi-structured questionnaire: The participants
were interviewed about their age, level of education,
occupation, history of drug uses, oral habits etc; and adata capture sheet for a Clinical oral examination using
modified WHO Oral Health Assessment 1997 Guidelines.
DMFT, periodontal disease and oral mucosal lesions
were recorded.
The questionnaire was designed in English language,
but translated to Bengali language. After the pilot study
on 20 persons, the final questionnaire was used.

Data collection

Two plastic boxes with different colors for instruments
were provided. One box was for transporting sterile
instruments only and was sterilized if contaminated. A
new set of sterile instruments was used for each subject.

Gloves were changed before the examination on every
subject and facemasks were changed every hour. Used
probes, mirrors, and other instruments were collected ina separate container and, cleaned, washed andautoclaved at the end of the working day. A clinical waste
bag was utilized for the disposal of used gloves, facemask,
wipes and clinical sheets.
The WHO Oral health survey guidelines and criteria(dmft/DMFT, CPITN) were used. The oral examination
was carried out without prior cleaning or drying of theteeth, using a plane mirror and dental curved probe. No
radiographic examinations were performed. The oral
examinations were carried out in two different places,
the referral clinics and ultrasound clinics.

Codes and criteria for Dentition status and treatment
need-DMFT/dmft:

0 Sound crowns: A crown was recorded as sound if it
showed no evidence of treated or untreated clinicalcaries. In addition, a crown with the following defects
was also coded as sound: white or chalky spots,
discolored or rough spots that were not soft to touchwith the metal CPI probe, stained pits or fissures in theenamel that did not have visual signs of underminedenamel, or softening of the floor or walls detectable with
CPI probe , dark, shiny, hard, pitted areas of enamel in a
tooth showing signs of moderate to severe fluorosis,
lesions that, on the basis of distribution or history,
appeared to be due to abrasion.
1 Decayed crown: Caries was recorded as present whena lesion in a pit or fissure, or on a smooth tooth surface,
had an unmistakable cavity, undermined enamel, or a
detectable softened floor or wall. A tooth with atemporary filling, or one which is sealed (code 6) but
also decayed was also included in this category. The CPI
probe was used to confirm visual evidence of caries on
the occlusal, buccal and lingual surfaces. Where any
doubt existed, caries was not recorded as being present.
2 Filled crown, with decay: A crown was consideredfilled, with decay, if it had one or more permanent
restorations and one or more areas that were decayed.
3 Filled crown, no decay: A crown was considered filled,
without decay, when one or more permanent
restorations were present and there was no caries
anywhere on the crown. A tooth that has been crowned
because of previous decay was recorded in this category.
A tooth that had been crowned for other reasons (e.g. a
bridge abutment), was coded as (7).
4 Missing tooth, as a result of caries: This code wasused for teeth that had been extracted because of caries
and was recorded under coronal status.
5 Tooth missing, for any other reason: This code wasused for teeth judged to be absent congenitally, or
extracted for orthodontic reasons, periodontal disease,
trauma, etc.
6 Fissure sealant: This code was used for teeth in which
a fissure sealant had been placed on the occlusal surface.
If a tooth with sealant had decay it was coded as (1).
7 Bridge abutment, crown, and veneer: This code wasused under coronal status to indicate that a tooth formed
part of a fixed bridge i.e. is a bridge abutment. It was also
used for crowns placed for reasons other than for caries
and for veneers or laminate covering the labial surface ofa tooth on which there was no evidence of caries or a

Eubios Journal of Asian and International Bioethics 28 (March 2018)
restoration. Missing teeth replaced by bridge pontics
were coded 4 or 5 under coronal status.
8 Unerupted crowns: This code was used for a tooth
space with an unerupted permanent tooth. Teeth scoredas unerupted were excluded from all calculation
concerning dental caries .This category does not include
congenitally missing teeth, or teeth lost as a result of
trauma, etc
9 Not recorded: This code was used for any tooth that
could not be examined for any reason.

Periodontal status

The methods recommended by the World HealthOrganization (WHO) for recording of periodontal
diseases have varied from Russell’s periodontal index to
the Community Periodontal Index of Treatment Need,
CPITN/CPI (Page and Eke, 2007). The WHO introduced
the CPI to provide profiles of the periodontal status of
populations and to enable countries to plan prevention
programs (Benigeri et al., 2000). The surveillance of oral
health at country level depends mainly on the CPI data
(Petersen and Ogawa, 2005). Periodontal status wasassessed using a specially designed lightweight CPITN
probe with a 0.5 mm ball tip with periodontal pockets
were measured from the edge of the free gingival to thebottom of the pocket. Using the epidemiological part of
the CPITN, the community periodontal index (CPI),(W.H.O: Oral Health Surveys, 1997) with the following
ten
index
teeth
were
examined(17,16,11,26,27,47,46,31,36,37) and six sextant per
individual, three indicators (gingival bleeding, calculus
and periodontal pockets) of the periodontal status wereused. The two molars in each sextant were paired forrecording and, if one was missing, no replacement wasused. Sextants with fewer than two teeth which were notindicated for extraction were excluded. If no index teethor tooth was present in the sextant qualifying for theexamination, all the remaining teeth in the sextant were
examined and the highest score was recorded for the
sextant.

Codes and criteria:

0 Healthy
1 Bleeding: observed, directly or by using a mouthmirror, after probing.
2 Calculus: detected during probing, but the entire blackband on the probe visible.
3 Pocket 4-5mm: gingival margin within the black bandon the probe.
4 Pocket 6mm or more: black band on the probe notvisible.
X Excluded sextant: less than two teeth present

Scoring of oral health conditions

For the researcher’s convenience the oral health status
was classified in 4 categories 0=healthy, 1=mild,
2=moderate and 3 severe oral health conditions. The
criteria which were evaluated in the proposed scoring
were based on the status of the oral tissues in disease
and health. The investigator rated the oral status of thesubjects as follows:
Score 0 = If healthy dentition, no decayed, no missing
and restored teeth, healthy periodontium and healthy
oral mucosa.

71

Score 1 = If less than 25% decayed, missing and abrasion
teeth, mild gingivitis mild peridodontitis are present.
Score 2 = If more than 25% and less than 50% decayed,
missing and abrasion teeth, moderate gingivitis andmoderate periodontits, xerostomia are present.
Score 3 = if more than 50% decayed, missing andabrasion teeth, severe gingivitis, severe periodontits andoromucosal lesion are present

Oral mucosa Examination procedure

The oral mucosa and soft tissues in and around themouth of all subjects were systematically examined. Any
abnormalities in the oral mucosa or the gingival or any
oral lesion were recorded on the data capture sheet. The
examination was thorough and systematic and was
performed in the following sequence:a) Labial mucosa and labial sulci (upper and lower).
b) Labial part of the commisures and buccal mucosa(right and left)c) Tongue (dorsal and ventral surfaces, margins)d) Floor of the mouthe) Hard and soft palatef) Alveolar ridges/gingival (upper and lower)
Two mouth mirrors were used to retract the tissues.
The following procedure was used and the following
codes were used to record the absence, presence orsuspected presence of the condition: The lips were
examined with the mouth closed and open. The colour,
texture and any surface abnormalities of the vermilion
border were noted. The mandible vestibule was
examined visually with the mouth partially opened. The
colour and any swelling of the vestibular mucosa wereobserved. The maxillary vestibule and fraenulum withmouth partially opened was examined. Using the planemouth mirrors as retractors and the mouth wide open,
the entire buccal mucosa extending from thecommisures and back to the anterior tonsillar pillar was
examined. Any changes in pigmentation, colour, texture
and mobility of the mucosa were noted. Alveolar ridges
were examined from all sides (buccaly, palatally,
lingually).
With tongue at rest and the mouth partially opened
the dorsum of the tongue was inspected for any swelling,ulceration, coating or variation in colour or texture. The
patient was then asked to protrude the tongue and theexaminer noted any abnormality of mobility. The
margins of the tongue were inspected with aid of mouthmirrors and then the ventral surface was observed.
While the tongue was elevated, the floor of the mouth
was inspected for swellings or any other abnormalities.
With the mouth wide open and the subject’s head tilted
backwards, the base of the tongue was gently depressed.
The hard palate was inspected first followed by the soft
palate. Any mucosal or facial tissues that seemed to beabnormal, as well as the submandibular and cervicallymph nodes, were palpated.

Reliability

Only one person (Dr. Anower) collected the data andinterviews, thereby ensuring standardization in the way
the questions were asked and recorded. Descriptive
statistics through SPSS were used to describe thedemographic factors. Chi- square test used to determine
correlation between the scale variables of the sample.

Eubios Journal of Asian and International Bioethics 28 (March 2018)72

The sampling was only conducted in Dhaka. As oral
health practice is related to education, it would be betterif could be able to recruit drug abusers from both urban
and rural areas. It could also be good to conducted acomparison study between drug abusers with non drug
abusers.

The monthly income of the 120 respondents
found that about 42% respondents said that they
have no income. 15% respondents earn below 5000
BDT per month, while around 43% of the
respondents earn more than 5000 BDT per month.

Ethical considerations

Table 1: Distribution of the respondents by thetypes of drugs abused (N=120)

Ethical clearance was taken from the appropriate
authority and ethics were maintained strictly throughout
the study. Ethical clearance was obtained from Ethics
Review Committee of Bangladesh University of Health
Sciences (BUHS). A request letter of cooperation writtenfrom the Bangladesh University of Health Sciences(BUHS) to the Drug Rehabilitation Center was taken thatwas involved in this study prior to the data collection
period. All the participants were given an explanation
about the objective of the study and their right toparticipate or not to participate in the study. An
Information sheet for participants in Bengali was also
given to each participant to read and it was also
explained by the investigator. All questionnaires andethical documents were translated into Bengali before
interview. The prospective participants were given freeopportunities to receive summary information of thestudy in writing before giving written consent and taking
part in the interviews of the research. Personal
information of the participants was keep confidential.

6. Results
6 .1 Socio-demographic characteristics
Among the study subjects 13% were below 20
years, 43% were of 20 to 29 years, 18% were of 30
to 39 years and 26% were of above 40 years old.
Among the subjects 91% were male and 9% werefemale. Most were married, 62% respondents were
married and unmarried were 35%.
The levels of respondent’s highest education was
20% both for higher secondary school anduniversity graduation. This was closely followed byPrimary level and high school level at around 19%
and 14% respectively. However, nearly 27% of the
respondents were illiterate.
Among the drug abusers 42% were unemployedeither being students, lost their jobs or doing
nothing, while 58.3% of drug abusers were
employed, businessmen, service holder and selfemployed, etc.

Type of drugs

Responses

Heroin% ofN% Cases
65 32.3% 55.1%

Injectable opioids
Methamphetamine (yaba)

4 2.0% 3.4%
36 17.9% 30.5%

Cannabis (Ganja)
Phensidyl
Total

51 25.4% 43.2%
24 11.9% 20.3%
201 100% 170%

*Multidrug abusers.
6.2. Pattern of drug abuse
Table 1 shows the distribution of the
respondents by abuse of drugs. Almost all werepoly-drug abusers, abusing more than one drug.
However, the most commonly used category ofdrugs was heroin were 55% of cases and 32%
responses. The second most abused drug wascannabis (ganja) were 43% of cases and 25%
responses. Methamphetamines (yaba) were 31% ofcases and 18% of responses. Alcohol and phensydil
were 10% and 12% responses among the
respondents.
The prevalence of opiate drugs heroin users
was 54% and injectable opioids was 3.3%. 60%
claimed to have taken cannabis or ganja, and also
over half, 54%, Methamphetamine (yaba). 34%
took Metham and 20% Phensy.
Table 2 shows 24% of the respondents are taking
drugs for 10 years or above, around 19% for 5-10
years, around 45% taking drugs for 1-5 years.
There were less in this sample who had used lessthan 6 months and 6months -1 year, 1.7% and 10%
respectively.

Table 3: Distribution of respondents in relation with type of drugs regarding respondent’s age (n=120)*According to respondents’ verbal statement, **yaba=Methamphetamine, ***ganja=Cannabis
Age group

HeroinInjectable opioid

Yaba**

Ganja***

Phensydil<20 years age(n=15, 12.7%)5(4.2%)0(0%)

5(4.2%)

8(6.8%)

2(1.7%)

20- 29 (n=49, 41.5%)21(17.8%)2(1.7%)

24(20.3)

21(17.8%)7(5.9%)

30 -39 years (n=22, 18.6%)

15(12.7%)1(.8%)

4(3.4%)

10(8.5%)5(4.2%)>40 years(n=32, 27.1%)24(20.3%)

1(.8%)

3(2.5%)

12(10.2%)10(8.5%)Total

65(55.1%)4(3.4%)

36(30.0%)51(43.2%)

24(20.3%)

Eubios Journal of Asian and International Bioethics 28 (March 2018)73

Table 5: Status of oral mucosa among the respondents
Status of the Oral Mucosa
Xerostomia
Leukoplakia
Methmouth
Total

Heroin9(10.7%)7(8.3%)
7(8.3%)
65

Injectable opioids2(2.4%)
4Yaba
13(15.5%)7(8.3%
41

Ganja
4(4.8%)
7(8.3%)
72

Phensydil2(2.4%)
3(3.6%)
24

Table 7: Status of oral health condition according to duration of abuses of drugs
Oral healthcondition
Healthy
Mild
Moderate
SevereTotal<6 month1(.8%)
1(.8%)
2(.8%)

Duration of abuses of drug
6 month-1year
1-5 year5-10 year8(6.7%)
8(6.7%)
3(2.5%)
4(3.3%)
32(26.7%)9(7.5%)
14(11.7%)11(9.2%)12(10.0%)54(45%)
23(19.2%)>10 year3(2.5%)
3(2.5%)
14(11.7%)9(7.5%)
29(24.2%)

Table 8: Associated determinants among subjects according to Oral Health Condition(n=120) Variables

Healthy

Mild/ModerateAge<25 years (n=51)
10 (19.6%)
41 (80.4%)≥25 years (n=59)
13 (18.8%)
47 (68.1%)
Sex
Male (n=109)
19 (17.4%)
81 (74.3%)
Female (n=11)
4 (36.4%)
7 (74.3%)
Marital status
Unmarried (n=74)
14 (18.9%)58(78.4%)
Married (n=46)
19.6 (9%)
30 (65.2%)
Educational level
Illiterate (n=32)
5 (20.8%)
16 (66.7%)
Primary to Secondary
7 (17.5%)
32 (80.0%)
School (n=40)
Higher School (n=24)
7 (29.2%)
17 (70.8%)
Graduation plus (n=24)
5 (20.8%)
16 (66.7%)
Occupation
Unemployment (n=50)
12 (24.0%)
32 (64.0%)
Employment (n=70)
11 (15.7%)
80 (56%)
Income status (BDT)
No income (n=50)
12 (24%)32 (64.0%)
Up to 5000 (n=18)
5 (27.8%)
13 (72.2%)
More than 5000 (n=52)
6 (11.5%)
43 (82.7%)
HeroinNon-user (n= 55)
10 (18.2%)
45 (81.8%)
User (n= 65)
13 (20.0%)43 (66.2%)
Methamphetamine (yaba )Non-user (n=84)
13 (15.7%)
62 (73.8%)
User (n=36)
10 (27.8%)
26 (72.2%)
Cannabis (Ganja)
Non-user (n=69)
22 (31.9%))38 (55.1%))
User (n=51)
1 (2.0%))50 (98.0%)
Duration of abuses of drugs
Up to 5 years
17 (25.0%)
51 (75.0%)
More than 5 year
6 (11.5%)
37 (71.2%)
Oral Hygiene Practices (Brushing frequency)
Two time a day (n=27)
7 (25.9%)
20 (74.1%)
Not two times a day
16 (17.21%)
68 (73.1%)(n=93)

Table 3 shows that 20 to 29 year aged
respondents have a high percentage (42%) of drug
abuse. Among 55% of heroin abusers, 20% wereSevereChi value

0 (0%)
9 (13%)

7.26

9 (8.3)0 (0%)

2.93

2(2.7%)
7 (15.2%)

6.6

p-value

0.026
.
.

0.231
.037

5 (15.6%)
1 (2.5%)
9.25

0.160

4.377

.112

7.010

0.135

0 (0%)
9 (13.8%)

8.66

.013

9 (10.7%)
0 (0%)

5.855

.054

27.734.000

0 (0%)
9 (17.3%)

14.6

.001

0 (0%)
9 (9.7%)

3.44

.179

0 (0%)
3 (7.5)6 (12.0%)
3 (4.3%)6 (12.0%)0 (0%)
3 (5.8%)9 (13.0%)0 (0%)

above 40 years of age, 18% were aged between 20
to 29 years, 15% respondents were 30 to 39 year
old and only 4% respondents were below 20 years.

Eubios Journal of Asian and International Bioethics 28 (March 2018)74

Table 2: Distribution of the respondents by
duration of abused of drugs
Time by years
Less than 6 months
6 months to 1 year
1 year to 5 year
5 year to 10 year
More than 10 year
Total

Frequency
2
12
54
23
29
120

Percent
1.7
10
45
19.2
24.2
100

Among 43% of cannabis (ganja) abusers 18%
respondents were 20-29 years old, 10%
respondents were above 40 years, 9% respondents
were 30-39 year and 7% respondents were below
20 years old. On the other hand among 30% of yaba(methamphetamine) users, 20% were 20-29 years.
Table 4: Oral Health Behavior
Variables
Percentage
Brushing frequency
Once/three/more than three times a
77.5%
day (Incorrect method)
Twice a day (Correct method)
22.5%
Schedule of cleaning teeth
Before breakfast/After every meal
76.7%
(Incorrect method)
After breakfast and before sleep at
23.3%
night (Correct method)
Materials used for cleaning teeth
Tooth powder/charcoal
18.3%
Tooth brush / past
81.7%
Use of mouth washes
Never
74%
Occasionally
16%
Once a day
10%
Twice a day
Use of floss
Never
92%
Occasionally
8%
Once a day
Twice a day
Time of last dental visit
Visited in last six months
4%
Visited previous year
37%
Factor determine the frequency of visiting dentist
Money and Bad Experience
25%
Money and fear
32%
Ignorance48%

6.3. Oral hygiene practices among illicit drug abusers
Table 4 describes the pattern of oral hygiene
practices among the illicit drug abusers. Regarding
brushing frequency, 78% of the respondents didn’t
brush their teeth regularly i.e. Once/three/morethan three times a day and only 22% respondents
brushed their teeth in a standardized method thatis twice a day. Around 23% of the respondents’schedule of brushing their teeth in the right way(after breakfast and before sleep at night) and 77%of the respondents schedule was wrong (before
breakfast/ after every meal). Most of theparticipants 74% never used floss to clean theirteeth. Only 4% of the participants visited dentist
within last six months.
6.4 Attitudes towards oral health related practices
Most of the participants explained that theyneglected their oral and personal hygiene becauseof low self-esteem, for example: “I didn’t know somuch about Oral hygiene and I didn’t care about
myself at al.” (Jashim, 12/1/2017)
Those who reported brushing their teeth said theywould ‘do it really quick, in less than a minute’.
Sometimes putting the brush in the mouth would
cause the drug user to ‘start heaving and feelingsick’. Only the few who were quite determinedattempted to try again once they ‘stop heaving’.
Many participants avoided dentists until the pain
became impossible to control. Most had selfmedicated for pain (especially dental pain). They
would take extra drugs for severe toothache
including ibuprofen, heroin and cocaine; in somecases injected directly into a tooth or gums. Someparticipants had even removed teeth themselves inthis way.
Because of previous treatment experience,
intensity of drug use and inability to keep
appointments, many respondents are not visiting
Dentist. Several described negative experiences andwere ‘petrified’ of dentists. Some even reported
getting up from the dental chair and running away
because they could not accept treatment. One
particular fear among participants was needle
phobia, e.g.: “I didn’t like it, especially that big needle
they put in your mouth. I hate it” (Yasin, 15/1/17)
Drug-using lifestyle, fear (needle phobia), money,
acceptance by dentist, waiting in dental chamberand low self-esteem acts as a barriers and prevent
them from visiting Dentist. Most of the respondents
expected more care about their oral health as wellgeneral health and it will be free of cost.
6.5 Oral conditions due to drug abuse
The 120 persons were examined by a dental
specialist. All respondents have carious teeth and
41% had fractured or broken teeth. Periodontal
health status was also not good. Calculus waspresent in 46% of participants, 68% had bleedingon probing, 57% had shallow periodontal pocket
and 12% had deep periodontal pockets. 65%
respondents (N=78) had healthy oral mucosa. The
rest of the respondents have unhealthy oral mucosa.
18% had xerostomia (dry mouth - loss ofsalivation), 8.3% had leukoplakia (a white patches
on oral mucosa called pre cancerous lesion) and8.3% had a methmouth lesion (bruxism, excessive
tooth wear, xerostomia, and rampant caries).
Table 5 shows that Xerostomia was observed in
15.5% abusing yaba, 8.3% alcohol, 10.7% heroin

Eubios Journal of Asian and International Bioethics 28 (March 2018)
and only 2.4% phensydil abusers. Leukoplakia
lesions 8.3% present in both heroin and ganja
abusers. Methmouth lesion were 8.3% present inboth heroin and yaba abusers.
Table 6: Dentition status measured by DMFT
index
DMFT
Mean ±SD
Median(Range)DMFT
5±2.295 (1-10)
Decayed teeth
3.4±1.8
3 (0-7)
Missing teeth
1.29±1.7
1 (0-6)
Filled teeth
0.3±0.7
0.0 (0-4)
DMFT= Decayed, missing and filled teeth, SD =Standard deviation from mean.
Table 6 shows the DMFT (decayed, missing andfilled teeth) score of the respondents’ dentition.
Almost all of the respondents have high DMFT
score with mean ±sd was 5±2.29. Among drug
abusers, all teeth were examined, it was observedthat the mean number of decayed teeth was 3.4
with sd 1.8; missing teeth was 1.29 with sd 1.7; andfilled teeth was 0.3 with sd 0.7.
For our convenience we have classified the oral
health status in 4 categories: healthy, mild,moderate and severe condition of oral health basedon the status of the oral tissues in disease andhealth. 19% had healthy oral condition, 41% mild,
33% moderate and 7.5% had severely bad oral
conditions.
Table 7 shows the oral health condition in respect
to duration of drug abuse. Severely bad oral healthcondition (7.5%) observed after above 10 years of
drug abuse. Moderate oral health was seen in 12%
in 1 to 5 years and observed in 9% after 5-10 yearsof drug abuse. Mild oral health observed after 6
months of drug abuse.
6.6. Inferential statistics
The relationship between different independent
variables (age, sex, marital status, and level of
education, occupation, income, type of drugs andduration of abuse of drug) was examined. Chi
squared test was applied wherever applicable.
Significant relationship was found in case of age
group, marital status, type of drugs [in case heroin,yaba and cannabis (ganja)] abuse and duration of
abuse of drugs (Table 8). *c2-test was used. The
level of significance at p<0.005
7. Poor Oral HealthIn this study we have noticed that, the oral
hygiene practice of drug abusers was not ideal andas a consequence they have poor oral hygiene andworse gingival, periodontal and mucosal health;higher caries experience; and higher prevalence ofxerostomia, meth mouth and leukoplakia. It may be

75

stated that poor oral hygiene and poor dental
health status among addicts compared to thegeneral population may be attributed due to thedirect effects of drug abuse as well as the indirect
effects of addiction such as unhealthy lifestyles andpoor oral self care.
The sample size of this study was determinedusing prevalence of dental diseases in drug users
reported in a previous study (Rooban et al., 2008)
and consecutive sampling was used. This method ofsampling, though a non-probability samplingtechnique, allows every available subject to be
included (Lunsford and Lunsford, 1995). The
sample in this study represents a young andpredominantly male population which reflects thedemography of those in drug rehabilitation
programs (Cheung Y Wet et al., 1999). The fact thaton average the participants of this study beganabusing drugs at 19 years of age confirms that drug
abuse is a problem which begins in teenage years(United Nations Office on Drugs and Crime. World
Drug Report 2000).
The major drugs used were heroin (opioids),
cannabis (ganja) and amphetamine-type stimulants
rather than cocaine or other in Bangladesh. The
most commonly used category of drugs was heroin
were 55% and second most abused drug wascannabis(ganja)
were
43%
and
methamphetamines (yaba) were 31% among the
respondents. Ray (2004) found alcohol, cannabis,
heroin and opium were the common drugs of abuse
for target communities in various parts of India
which is almost a similar pattern of drug abuse in
our study.
The present study found poor oral health status
and negligence for oral hygiene practices among
drug addicts. Oral hygiene practices of the drug
users were alarming with more than three-quarterof the respondents (78%) cleaning their teeth in awrong way. Poor oral hygiene practices may be dueto the lack of concern for overall personal hygiene,
resulting from drug dependents, consumption andwithdrawal (DSM-IV criteria: Jaffe, 2000). 74% of
the respondents had never used moth washes and
92% had no idea about dental floss.
Consciousness about oral and general health waspoor and only 4% respondents said that they had
visited a dentist in the past 6 months. Schedule ofdental check-up was also poor, only 37%
respondents visiting to a dentist once in a year.
Ignorance (48%), money-fear (32%) and moneybad experience (25%) are the main obstacle for the
respondents to visit a dentist. Use of dental services
was inhibited by low priority for oral health, lowself esteem, addiction state, needle phobia, ability
to self-medicate and organizational factors in theirlifestyles. Most of the participants told, reason for
dental visit was their broken tooth. Similarly,

76

Eubios Journal of Asian and International Bioethics 28 (March 2018)(Robbinson) reported that a number of participants
said that they frequently ended up in hospitalcasualty departments because of accidents.
Analysis of the individual components of mean
DMFT value showed that the mean number ofdecayed teeth (3.98, sd 2.5 and range 0-10)
constituted the major part of the index, indicatinghigh caries prevalence among the drug users.
Significantly lower numbers of filled teeth (mean0.5) was recorded amongst drug users, suggestingthat drug abusers rarely received comprehensive
dental care.
This indicates that in addition to poor oral healthand corresponding needs, they have difficulty inaccessingdentalservices.
Concerned
administration of rehabilitation center and NGOs
should be given more importance on accessing
more dental services of drug users. Also, symptoms
of caries may be masked by pharmacological effects
of drugs and in case of severe pain these subjects
may self-medicate (Robinson et al., 2005).
The periodontal status of the drug users wasfound to be poor and only 11% found healthy
periodontium. Previous studies (Du et al., 2001;
Scheutz, 1984) have also reported poor periodontal
health among drug users. Analysis of community
periodontal index (CPI) of treatment needs
indicates that majority of the drug users have
bleeding pocket (68%) and 57% of the respondents
had shallow pocket (4-5mm) and they needs
professional plaque control (scaling and polishing).
12% drug users needs deep scaling, root planningand surgical procedure. This may be attributed totheir poor oral hygiene and concomitant heavy useof tobacco. Further, addictive drugs, particularly
opiates have been found to impair cell division,
thereby tilting the balance towards breakdown oftissue and failure to achieve repair andregeneration (Reece, 2007).
The results also showed that 49% had mild oral
health condition, 33% moderate oral healthcondition and 8% had severely bad oral healthcondition. 35% respondents had unhealthy oral
mucosa. Around 18% have xerostomia, 8% haveleukoplakia (pre cancerous lesion) and 8% havemethmouth lesion. Chi squared test was applied
wherever applicable. Significant relationship (at thelevel of significance at p<0.005) was found in caseof age group, marital status, type of drugs [in caseheroin, yaba and cannabis (ganja)] abuse andduration of abuse of drugs.
The findings of this study reflect the oral healthstatus of disadvantaged group of drug abusers inselected center. Bangladesh is a nation with diverse
socio-cultural and regional variations. Therefore,
further comprehensive study comprising a big
population is recommended to get a clearer pictureof drug abuser. The possibility of social desirability

bias while answering the questions on drug use andoral health practices cannot be ruled out due tointerview
based
administrationofthequestionnaire; however, measures were taken to
reduce the bias.
Like other epidemiologic field studies, this study
did not include radiographs as part of the clinicaldental examination because of common ethical andlogistical constraints. This approach may
underestimate the prevalence and severity ofdental caries and periodontal disease.
In conclusion, the findings suggest that illicit drug
use is independently associated with poor
periodontal health. It can be inferred that it is not
only the direct effect of the illicit drugs, but also theindirect influence of factors such as associated low
socioeconomic status and lifestyle pattern that
contributes to poor oral health in thisdisadvantaged group.
8. Drivers of Drug Abuse
Family problems could be a very critical factor for
abusing drugs. An absent father or mother is most
likely to produce an addict child. It is very difficult
to maintain discipline in a family without parents.
Moreover, lack of bonding between parent & childdrive someone for drugs. Participants also
described lack of self-esteem and peer pressure
also drove them to a drugs addict. They feelsomething is wrong with them. They feel guilty andresponsible for their parents’ problems. Some ofthe participants described they addicts due tocuriosity and experiment with their friends. Parentsof few participants have a history of drug addict.
Parental drug use could be a risk factor of drug
addicts. Cultural influence like TV adds also
influenced them to a drug.
9. Steps to Addiction
Participants reported that firstly they took drugs
as an experiment. The most common drug used wascigarettes and alcohol. They trust the drug will
make them feel better. Then they started use
occasionally, just on the weekends. Next they took
regularly, almost every day of the week. All
activities revolve around drugs and friends who use
drugs. Harmful dependence developed to use thedrug to get high. Finally they took daily and usually
all day long. The user has to take the drug to feel
normal. The brain chemistry has changed to thedrug is part of the normal function of the brain. If
the drug is stopped, withdrawal sets in.
10. Socio-demographic features of the
respondents
The sample in this study represents a few young
teenagers, with 43% of 20 to 29 years, 18% of 30 to
39 years old, and predominantly a male population
which reflects the demographics of those in drugEubios Journal of Asian and International Bioethics 28 (March 2018)
rehabilitation programmes (Cheung et al; 1999).
The fact that on average the participants beganabusing drugs at 21 years of age confirms that drug
abuse is a problem which begins in teenage years(United Nations Office on Drugs and Crime (World
Drug Report 2000).
The socioeconomic status was found poor among
the drug abusers. Almost half of the respondents(42%) have no income, depended on family and
15% of respondent’s income was below 5000 Taka.
Frequent unemployment and economic difficulties
are well recognized consequences of drug
dependence (Hanson et al., 2005; Ray, 2004), thismay could moral deterioration of the drug abusers.
To obtain money for the drug the addict often turns
to crime and increased many social problems in ourcountry like crime in the form of drug trafficking,theft and prostitution.
Drug abuse has a major medical problem withextensive legal, social and even political problems.
A person made tolerant to a large dose of one
narcotic is also cross-tolerant to many of the effects
of another narcotic. Indiscriminate use of any ofthese drugs becomes dangerous and produces a
gradual mental, physical and moral deterioration of
the individual and sometimes also sexual
perversions or crime. To get money for drugs the
addict often turns to prostitution or crime. The
majority of drug victims are neurotic individuals
who are mentally unbalanced.
11. Responsibilities of the government
Government and NGOs can play a great role inthis regard. They need to invest in education,
research and prevention programs for those at highrisk of substance abuse and the public in general.
They should also encourage the use of treatment
facilities that really work. By effectively treating
those with addictions and working harder toprevent new people from abusing drugs or alcohol,
we will be really dealing with the problem ofsubstance abuse.
12. Conclusions
Drug abuse is a major cause of multiple physicaland mental problems such as cardiac crisis,
respiratory depression, liver cirrhosis, nephropathy,
infectious diseases such as hepatitis, AIDS, andtuberculosis, injury-associated disability, mental
disorders such as depression, and oral healthproblems. The number of drug abusers in Asia is
sharply rising. The incidence of addiction to certain
drugs in Bangladesh is alarming particularly
amongst young people in our country.
In this study most of the participants could notcomplete their education. Most of the participants
were in the low income group. Study showed thatmajority of the respondents were addicted toheroin, cannabis (ganja) and/or yaba for a long77

time. We have also noticed that the majority of the
respondents did not maintain their oral healthpractice properly. Teeth cleaning practice showedthat all respondents cleaned their teeth once in aday, which is not a healthy practice. For getting
maximum benefit by oral hygiene practice one
should brush his teeth twice daily with a toothbrush and tooth paste. Regular use of mouth washand dental floss will give extra protection for oral
health. However, this study described that drug
abusers oral condition was not healthy.
Based on findings from this study we canconclude that drug abusers had inferior oral
hygiene practices and as a consequence poorer oral
hygiene and worse gingival, periodontal andmucosal health; higher caries experience; andhigher prevalence of xerostomia, meth mouth andleukoplakia. A large proportion of oral diseases may
be preventable among drug abusers through proper
prevention and rehabilitation of oral health andalso cessation of drugs among them. The changing
attitude can be occurred by giving adequate
information and motivation to the respondents. So
dental health and public health education is neededfocusing on special needs of population to improvetheir quality of life expectancy
12. Recommendations
If we really want people to stop abusing drugs,
we need to know why people are taking drugs andhow it happens. Considering the causes discussed
above and findings of this study, the following
recommendation are made for prevention of drug
abuse.
• Research should be continued on the factors
which influence drug abuse and further
exploration is needed with a large scalecommunity based study to find out theprevalence, knowledge and attitudes regarding
drugs abused related oral health problem.
• Oral health service should be introduced in every
rehabilitation center to the oral self care practice,
rapid diagnosis and treatment of oral disease
among the drug abusers.
• Rules and regulation should be strict to preventthe transport and sales of drugs in our country.
• Proper educational programmed should bearranged among the workers of rehabilitation
center to educate the drug abusers about oral
health.
• We should train parents, teacher, imams(religious leaders) and community leaders about
the harmful effects of drugs and also proper oral
hygiene so that they can build awareness to thecommunity people through dissemination
information and motivate the people to give up
drugs addiction.

78

Eubios Journal of Asian and International Bioethics 28 (March 2018)• These findings should be used as a baseline toincrease focus on oral health promotion
strategies for drug addiction populations byformulating public health programs stressing on
primary and secondary care for prevention andearly treatment of oral disease.
• Every dental professional should be aware of oral
problems associated with drug abused andstrongly motivate their patients by drugs
cessation counseling to quit drugs using and thedentist may take an active role in drugs
prevention counseling.
13. Acknowledgements

We appreciate the comments and support of Prof.
Shamima Parveen Lasker, General Secretary of
Bangladesh Bioethics Society; Prof. MA Hafeez, Head of
the Department of Biostatistics, BUHS; and Prof. Liaquat
Ali, Vice Chancellor, Bangladesh University of Health
Sciences (BUHS).

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For forthcoming conferences see: www.eubios.info or
www.ausn.info Email to Darryl@eubios.info.
Nineteenth Asian Bioethics Conference (ABC19): Bioethics for
Smart Living in Asia and Beyond: Taiwan as a hub for nurturing
international partnerships and sustainable practices, 13-16
November 2018, Kaohsung and Pingtung, Taiwan.
Twelfth Kumamoto University and AUSN International Bioethics
Roundtable (KBRT12): Bioethics in the 21st Century, 1-2 December
2018, Kumamoto University, JapanEJAIB Editor: Darryl Macer
Associate Editor
Nader Ghotbi (Ritsumeikan Asia Pacific University(APU), Japan)

Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico),Angeles Tan Alora (Philippines), Atsushi Asai (Japan),
Alireza Bagheri (Iran), Gerhold Becker (Germany), Rhyddhi
Chakraborty (India/UK), Shamima Lasker (Bangladesh),
Minakshi Bhardwaj (UK), Christian Byk (IALES; France), Ken
Daniels (New Zealand), Ole Doering (Germany),
Amarbayasgalan Dorjderem (Mongolia), Hasan Erbay(Turkey), Soraj Hongladarom (Thailand), Dena Hsin
(Taiwan), Rihito Kimura (Japan), Abby Lippman (Canada),
Umar Jenie (Indonesia), Nobuko Yasuhara Macer (Japan),
Masahiro Morioka (Japan), Anwar Nasim (Pakistan), JingBao Nie (China, New Zealand), Pinit Ratanakul (Thailand),Qiu Ren Zong (China), Hyakudai Sakamoto (Japan), Sangyong Song (Republic of Korea), Takao Takahashi (Japan),
Noritoshi Tanida (Japan), Ananya Tritipthumrongchok(Thailand), Yanguang Wang (China), Daniel Wikler (USA),
Jeong Ro Yoon (Republic of Korea).

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