According to the recent World Health Organization (WHO) reports, an estimated 2.3 billion people all over the world still rely on solid fuels like wood, coal, charcoal, crop waste, and dung for cooking at homes [1]. It has been reported that in Southeast Asia around 1 billion people depend on solid fuels for their daily energy needs, mainly for cooking and heating [2]. It was observed that women and children, especially those taking care of household chores such as cooking, and collecting firewood and other biomass fuels had to bear the maximum burden on their health because of these polluting fuels and technologies used at homes for cooking and other purposes [1]. According to a recent study it was reported that in India around 64% of the households used solid fuels, with more of rural population using solid fuel (81%) compared to urban population (26%) [3]. It was observed that smoke released from burning of biomass fuels emitted numerous harmful gases and pollutants, including particulate matter, carbon monoxide, nitrogen dioxide, and carcinogenic organic air pollutants in concentrations that were higher than those associated with air pollution in polluted cities [4,5]. The ill effects of exposure to the biomass smoke have been reported to be highest among women, as they are the ones who cook food at homes and young children who stay along with them.6 In the past some years, a significant association has been reported between exposure to biomass smoke and development of anemia among women and children [6,7,8,9].

Anemia is a serious public health problem prevalent amongst both developing and developed countries. It is associated with increased morbidity and mortality in pregnant women and children [10]. The community-based studies related to impact of biomass fuel smoke exposure in rural women are very scarce.

Objective

Community-based prospective study was carried out to know the contribution of biomass fuel use to anemia in pregnant women of a rural remote region.

Study setting: Community based study was carried out in rural tribal communities of remote, forestry and hilly region in 100 villages around the village with health facility.

Study Design: Prospective observational study.

Study period: Two years

Inclusion criteria: All those diagnosed with pregnancy during the study period, residing in the 100 villages around the village with health facility (study center) and willing to be a part of the study were randomly enrolled as participants.

Exclusion criteria: Non pregnant women, women with advanced pregnancy, post-partum and post-abortal women and those not willing to be a part of the study were excluded.

Sampling technique: Existing maternal care information system for knowing about the women with early pregnancy in 100 study villages by Anganwadi workers, Subcenter nurses, Nurse Midwives was used. Women were then enrolled as study participants.

After approval of the institute’s ethics committee, and informed consent from the participants, the study was conducted over two years. Predesigned tool was used for collecting and recording information based on responses, and was recorded by the trained field assistant. None of the participant was given the tool to fill. In the first year of the study, a survey was conducted to acquire base-line information regarding living conditions, fuel used, ventilation in huts, etc. in the villages. This was followed by random division of 100 study villages into two groups with 50 villages as intervention villages and 50 as control villages. The intervention villages were further subdivided into two groups; group I: consisted of 40 villages where advocacy for protection from smoke of biomass fuel was done at regular intervals, and group II consisted of 10 villages where in addition to the advocacy for protection from smoke, chimneys were also installed on roofs of those huts which lacked windows for exit of biomass fuel smoke. The control villages (50 villages) neither had advocacy against protection from biomass fuel smoke, nor chimneys installed on roof tops of huts with poor ventilation. After identifying and recording all the pregnant women in intervention and control villages, their previous hemoglobin measured during antenatal checkups were recorded. This was followed by repeat measurement of hemoglobin of all the pregnant women by research assistant using Mission’s Electronic hemoglobinometer for uniformity of data. The hemoglobin of these pregnant women was checked for a maximum of five times (minimum 3 times for all) after their first trimester and mean hemoglobin value was then calculated for analysis. Grading of anemia was done using following cut-offs for hemoglobin, Non-anemic Hb≥11g/dl; mildly anemic ≥9g/dl to < 11g/dl; moderately anemic ≥7g/dl to < 9g/dl; severely anemic ≥5g/dl to < 7g/dl, and very severely anemic <5g/dl.

The mean hemoglobin values were analyzed and compared between the pregnant women residing in the intervention and control villages to know the impact of biomass fuel smoke exposure.

Statistical Analysis

The data was statistically analyzed using Statistical Package for the Social Sciences (SPSS) software version 21.0. The numerical data was presented as numbers and percentages and categorical variables as frequencies or rates wherever needed. Comparison of categorical variables was done using the chi-square test and a p-value <0.05 was considered statistically significant.

There were a total of 3400 pregnant women in all 50 intervention villages. In 40 intervention villages where advocacy regarding protection from smoke of biomass fuel was conducted at regular intervals, a total of 2135 pregnant women reported use of biomass fuel for cooking, water heating and heating of their homes. Of these 2135 women, majority were 20-29 years of age (57.3%), illiterate (40.0%), homemakers (48.1%), belonged to lower economic class (48.8%) and had 2-3 children (53.2%). Of these 2135 women exposed to biomass fuel smoke, 252(11.8%) were non-anemic with hemoglobin ≥11.0 g/dL and 1883 (88.2%) were anemic. Of these 1883 anemic women, 710 (37.7%) had mild anemia, 654 (34.7%) moderate anemia, 341(18.1%) severely anemic and remaining 178 (9.5%) had very severe anemia. It was observed that the majority of women who developed severe (<7g/dL) and very severe anemia (<5g/dL) were less than 30 years of age, illiterate, home makers, belonged to lower economic classes and had only one birth. Table 1 depicts the correlation of sociodemographic features with the development and severity of anemia in pregnant women exposed to biomass fuel smoke during cooking and heating (Table 1). Similarly in the 40 intervention villages where advocacy regarding protection from smoke of biomass fuel was conducted, a total of 565 pregnant women reported no use of biomass fuel in their homes. Of these 565 women, majority were of 20-29 years of age (65.3%), middle or high school educated (50.3%), semi-skilled by occupation (29.7%), belonged to middle-upper economic class (48.8%) and had 2-3 children (54.2%). Of these 565 non-biomass fuel user women, 67(11.9%) were non-anemic with hemoglobin ≥11.0 g/dL and 498 (88.1%) were anemic. Of these 498 anemic women, 188 (37.8%) had mild anemia, 140 (28.1%) moderate anemia, 108 (21.7%) severely anemic and remaining 62 (10.9%) had very severe anemia. Table 2 depicts the correlation of sociodemographic features with the development and severity of anemia in pregnant women not exposed to biomass fuel smoke during cooking and heating (Table 2). Hence, of the 40 intervention villages, among total of 2700 pregnant women 79.1% used biomass fuel and 20.9% women were non users of biomass fuel (p=0.001). Furthermore, it was observed that of the 2700 women, 69.7% women who had anemia were exposed to biomass fuel smoke compared to only 18.4% women not exposed to biomass fuel (p=0.001).

In the remaining 10 intervention villages where chimneys were also fixed on the roof tops of houses with poor ventilation, there were a total of 700 pregnant women. Of these 700 women, 517 (73.9%) women reported use of biomass fuel in their houses and the remaining 183 (32.1%) did not use biomass fuel. Of 517 women who reported biomass fuel use, majority were of 20-29 years age (52.8%), educated up to primary level (48.0%), homemakers (45.6%), belonged to lower economic class (54.9%) and had 2-3 children (65.2%). Of these 517 women exposed to biomass fuel smoke, 51(9.9%) were non-anemic with hemoglobin ≥11.0 g/dL and 466 (90.1%) were anemic. Of these 466 anemic women, 104 (22.3%) had mild anemia, 215 (46.1%) moderate anemia, 86 (18.4%) severely anemic and remaining 61 (13.1%) had very severe anemia. Table 3 depicts the correlation of sociodemographic features with the development and severity of anemia in pregnant women exposed to biomass fuel smoke during cooking, water heating and heating houses with chimney fixed (Table 3). Of 183 women who did not use of biomass fuel and had no chimneys fixed to their roof tops, majority were 15-19 years of age (53.6%), middle or high school educated (38.3%), semi-skilled workers (29.5%), belonged to middle-lower economic class (37.2%) and had 2-3 children (60.1%). Of these 183 women not exposed to biomass or any other fuel smoke, 24 (13.1%) were non-anemic and 159 (86.9%) were anemic. Of these 159 anemic women, 45 (28.3%) had mild anemia, 74 (46.5%) moderate anemia, 26 (16.4%) severely anemic and remaining 14 (8.8%) had very severe anemia. Table 4 depicts the correlation of sociodemographic features with the development and severity of anemia in pregnant women not exposed to biomass or any other fuel smoke due to presence of chimney in their houses (Table 4). Of the 10 intervention villages, where chimneys were installed on the roof tops of houses, of total 700 pregnant women were observed and it was revealed that 73.9% used biomass fuel and 32.1% women were non biomass fuel users (p=0.001). Furthermore, it was observed that of 700 women, 66.6% women who developed anemia were biomass fuel users compared to only 22.7% women who were non biomass fuel users (p=0.001).

In 50 control villages where no intervention was done, there were a total of 2818 pregnant women. Of these 2818 women, 2287(81.2%) reported use of biomass fuel at their homes and the remining 531 (18.8%) were non biomass fuel users. Of the 2287 women exposed to biomass fuel smoke, the majority were 20-29 years of age (57.8%), illiterate (41.3%), homemakers (51.1%), belonged to lower economic class (49.3%) and had 2-3 children (55.4%). Of these 2287 women exposed to biomass fuel smoke, 279(12.2%) were non-anemic and 2008 (87.8%) were anemic. Of the 2008 anemic women, 720 (35.9%) had mild anemia, 777 (38.7%) moderate anemia, 323 (16.1%) severely anemic and remaining 188 (9.4%) had very severe anemia. Table 5 depicts the correlation of sociodemographic features with the development and severity of anemia in pregnant women exposed to biomass fuel smoke during cooking and heating in non-intervention villages (Table 5). Of 531 women who did not use of biomass fuel at their houses, the majority were 20-29 years of age (66.7%), middle or high school educated (46.7%), semi-skilled workers (28.8%), belonged to middle-lower economic class (27.5%) and had 2-3 children (54.4%). Of the 531 non biomass fuel user women, 46 (8.7%) were non-anemic and 485 (91.3%) were anemic. Of these 485 anemic women, 136 (28.0%) had mild anemia, 238 (49.1%) moderate anemia, 85 (17.5%) severely anemic and remaining 26 (5.4%) had very severe anemia. Table 6 depicts the correlation of sociodemographic features with the development and severity of anemia in non-biomass user pregnant women in non-intervention villages. (Table 6).

Of all 50 control villages, a total of 2818 pregnancies were reported and it was revealed that 81.2% used biomass fuel and 18.8% women were non biomass fuel users (p=0.001). Furthermore, it was observed that of 2818 women, 71.3% women who had anemia were exposed to biomass fuel smoke compared to only 17.2% anemic women who were not exposed to biomass fuel (p=0.001).

When intervention and control villages were compared, it was revealed that a total of 2652 (78.0%) women reported use of biomass fuel and 748 (22.0%) did not use in 50 intervention villages and in 50 control villages also 2287 (81.2%) women reported use of biomass fuel and 531 (18.8%) did not use. Moreover, in the intervention villages, a total of 3006 (88.4%) women developed anemia, of which 2349 (78.1%) were biomass users and 657 (21.9%) were non-users. Similarly, in control villages, a total of 2493 (88.5%) women developed anemia, of which 2008 (80.5%) were biomass users and 485 (17.2%) were non-users.

Furthermore, when compared with the incidence and severity of anemia in pregnant women a significant difference was observed among interventional villages where biomass fuel was used and only advocacy was provided and in 10 villages where both advocacy and chimney installation was done (p=0.001). Similarly, when compared with the incidence and severity of anemia in pregnant women a significant difference was observed between 40 biomass-user intervention villages and 50 biomass-user control villages (p=0.001) and a statistically significant difference was observed between 50 biomass-user control villages and 10 biomass-user intervention villages where both advocacy and chimneys were installed (p=0.001). Incidence and severity of anemia was significantly less in 10 intervention villages compared to 50 control and 40 intervention villages where only advocacy was done. It was found that biomass fuel was commonly used in villages as an important source for cooking and other household chores. Women exposed to biomass fuel smoke were at a greater risk of developing anemia. Interventions like advocacy about protection from ill effects of biomass fuel. Installation of chimneys on roof tops played a significant role in reducing the incidence and severity of anemia in pregnant women.

For further infermation please go through this link: https://www.pubtexto.com/pdf/?exploring-the-effects-of-biomass-fuel-usage-on-anemia-in-pregnant-women-of-rural-remote-forestry-and-hilly-region-a-communitybased