Vehicle Consumption: Driving Factor of Air Pollution

            Air pollution in India has become a huge problem, especially because of the rise in population, industrialization, and per capita income.  In 2001 the growth rate in urban India was 17.97% and estimates have it that in 2000 there was 40 million vehicles driven in India with 30% being in 12 major cities (Nagdeve, 2004).  Such increases have led to a significant rise in the number of cars being driven in India.  Cities are the industrial hubs of a nation and as the cities have grown in India, industrialization has also grown.  However, the lack of planning in placement of industries have led to them being placed in urban and suburban areas that along with vehicle emissions has led to dangerous levels of air pollution.  Currently in India 1.5 billion people are exposed to dangerous levels of air pollution and 673,000 of those die each year from air pollution related diseases, such as respiratory illnesses (Nagdeve, 2004).

            Most people focus on respiratory diseases in discussions related to air pollution.  However, more research needs to look at how air pollution can also have an effect on vitamin D deficiencies among children.  Children living in slums are already at high risk for developing vitamin D deficiency because their families cannot afford to purchase foods that have vitamin D and they are not able to grow such foods.  Therefore, the main source of vitamin D for those children would be from the sun’s ultraviolet B radiation that causes the formation of vitamin D on the skin.  However, when pollution is high the haze blocks the radiation from reaching the skin.  Slums are most likely to be affected by air pollution because industries, if given the chance, build factories closer to the slums rather than more modern areas of a city.  A study was conducted that compared prevalence of vitamin D deficiency among children in a highly polluted area of Delhi  and among those living in less polluted areas of Delhi.  The study looked at 34 children and found that twelve children in the areas of high pollution were vitamin D deficient and three were severely deficient.  Thus, governments need to realize the far reaching health impacts of pollution and how the poor are often most affected.

            The biggest source of vehicular air pollution is motorized two wheeled vehicles, which makes up 2/3rds of the total vehicles in India (Badami, 2005).  The two wheeled vehicles are more popular than four wheeled vehicles because they are more affordable.  Interestingly enough, these smaller vehicles actually produce more carbon monoxide and hydrocarbons than buses (Badami, 2005).  The cause of pollution from these vehicles largely comes from the lack of maintenance that would reduce the emissions, and from the intense congestion of the roads.  Road congestion in India is largely due to inadequate road infrastructure and lack of traffic control which increases carbon monoxide and hydrocarbons emissions per vehicle-kilometer by 200% or more (Badami, 2005, 197).   

            Buying of vehicles is not going to slow down anytime soon as population and incomes keep growing.  Therefore, India must begin to invest in programs and policies that will curb the amount of air pollution.  One of the major policies that India is introducing to alleviate this problem is to increase limited access expressways in order to alleviate traffic.  Another policy that may not be as costly and will help control the amount of pollution in the air is increasing urban tree planting.  While there is little hard empirical evidence about the impact urban trees has on air quality overall, urban vegetation can reduce ozone formation through reduction in the heat island effect (Pataki, 2011).  The United States has also recognized the potential benefits of urban vegetation.  In the American Clean Energy and Security Act of 2009, it is stated that for every 100 trees planted, 300 pounds of air pollution and 15 tons of carbon dioxide in the air is removed (Pataki, 2011, 33).

            Looking at long term solutions, India will have to invest in alternative fuel sources for vehicles, as the US has begun to do in recent years.  This is the only way to ensure that significant reductions in emissions will be made in the future in the transportation sector.  One of the major projects that the Indian government is looking into is electric cars.  The Ministry of Non-Conventional Energy Sources developed this program to develop and deploy battery operated vehicles.  The downfall of the current project is that the ministry is relying on lead batteries, which have a limited life span and limit the driving range.  Therefore, the ministry will have to look into rechargeable lithium batteries in the future (“Renewable Energy,” 2007, 67).  Air pollution is a worldwide problem, and while India does not necessarily have an equal share in worldwide carbon emissions, the air pollution in India is causing very localized problems that must be addressed.

References:

Agarwal, K.S., et al. (2002). The impact of atmospheric pollution on vitamin D status of infants

and toddlers in delhi, india. Archives of Disease in Childhood, 87: 111-113. Retrieved from http://adc.bmj.com/content/87/2/111.full

Badami, M.G. (2005). Transport and urban air pollution in india. Environmental Management,

36(2): 195-204. Retrieved from http://www.regionomics.com/INDUS/Badami-envl_mgmt.pdf

Renewable Energy and Energy Efficiency Status in India. (2007). ICLEI South Asia Report.

Nagdeve, D.A. (2004). Urban air pollution and its influence on health in india. ENVIS, 1(3).

Retrieved from http://www.iipsenvis.nic.in/Newsletters/vol1no3/Nagdeve.htm

Pataki, D.E., et. al. (2011). Coupling biogeochemical cycles in urban environments: ecosystem

services, green solutions, and misconceptions. Front Ecological Environment, 9(1): 27-36.

Biofuels: Not Just an Energy Issue

            With an increasing demand for energy from an increasing population India is currently scrambling to try and increase energy production while at the same time trying to decrease its dependence on fossil fuels.  India currently receives 51.1% of its energy from coal which is one of the dirtiest sources of fuel available (Hassan, 2009, 7).  India is attempting to invest in more renewable energy sources such as wind, solar, hydro, and biomass to increase cleaner energy sources.  Each source has its positives and negatives; specifically in biomass production the problem is not encouraging people to use biomass or even developing the technology to convert biomass to usable energy. The issue in India is developing a clean and safe method of utilizing biomass.  The 2001 Census showed that about 72% of all homes use traditional forms of energy such as firewood, crop residue, wood chips, and cow dung for cooking (Hassan, 2009, 7).  For all of India, 40% of the total energy supply comes from energy sources such as wood and cow dung.  The rural areas are largely the populations that are using these non-traditional energy forms due to lack of available electricity.

            Traditional biofuels have been used for many centuries among rural people but it is now being recognized that the indoor air pollution resonating in these homes is of higher concentrations than outdoor pollution caused by fossil fuels.  Indoor pollution is a sign of the inequality between developed and developing nations.  While industrialized countries like the US are mostly concerned with outdoor air pollution, the problem in many developing countries is indoor pollution.  These health risks are mostly due to the fact that such households are using fixed mud hearths that are made of clay and stone and are closed on three sides.  These open stoves are built inside poorly ventilated homes made of wood and crop residues with mud walls and roofs made of wood and crop residues covered with clay.  Thus, the smoke from the biofuels has no chimney to escape from and no ventilation (Hassan, 2009) which causes severe indoor air pollution. 

Not surprisingly women and children are the most affected by the use of biofuels in homes.  Women are the most affected because they spend about 90% of their day inside exposed to biofuels.  One study was done in Bishnah, located in Jammu, where 6200 individuals were studied.  It was found that there was a 25.3% prevalence of cataracts in the homes that used biofuels as their primary fuels due to the smoke from the combustion.  Of those cases, 70.4% were female because of the length of time of exposure (Hassan, 2009).  There are many other diseases associated with indoor pollution including respiratory illnesses, cancer, and asthma.  The World Health Organization estimated that indoor smoke from biofuels caused about 36% of disability adjusted life years lost from lower respiratory disease, 22% from chronic obstructive pulmonary disease and 1-5% from lung cancer (Wilkinson, 2007, 7).  The risk for disease is even greater for infant populations.

            Indoor air pollution has been linked to an increased risk of respiratory illnesses, low birth weight, stunting, and infant mortality in babies.  One study looked at two rural blocks in Tamil Nadu, observing over 11,000 babies and what the effects of uses of biofuels were on their health from birth to 6 months old.  Of all the households that were observed, 92.3% of them used wood or dung as their primary fuel source (Tielsch, 2009, 1351).  It was found that smoke from the combustion of biofuels was linked to a 49% increase in risk of low birth weight, 34% increase in respiratory illness, and 21% increase in 6 month infant mortality (Tielsch, 2009, 1351).  Exposure was also linked to a 45% and 30% increase in a risk of being underweight and stunting at 6 months of age.  One of the main causes for the use of biofuels was low socioeconomic status measurements including roof material, ownership of household items, and maternal education.

India is now using more modern techniques for biomass energy including the use of biogas.  Biogas has been used for small, rural and off-grid applications and attempts to provide rural areas with safer alternatives for energy.    Biogas is a good alternative because it does not compete for food resources but is produced from animal waste, crop residues, and waste from industrial and domestic activities that is then converted to methane gas.  This form of energy can easily be used as a source of heat for cooking, space cooling, refrigeration, and used as fuel in gas lamps.  There are 4 million family size biogas plants in the country and it is expected to rise to 12 million plants in the near future (Arora, et. al, 2010, 67).  Given the large population and density of cattle, biogas seems to be a good and healthy alternative to traditional biomass methods.

References:

Arora, D.S., et. al. US Department of Energy, National Renewable Energy Laboratory. (2010).

Indian renewable energy status report. US Department of Energy

Hassan, G., et. al. (2009). Domestic smoke pollution from biomass fuel combustion and

increased prevalence of cataracts in jammu and kashmir, india. Annals of Tropical Medicine and Public Health, 2(1): 31. Retrieved from http://www.atmph.org/article.asp?issn=1755-6783;year=2009;volume=2;issue=1;spage=31;epage=31;aulast=Hassan

Tielsch, J.M., et. al. (2009). Exposure to indoor biomass fuel and tobacco smoke and risk of

adverse reproductive outcomes, mortality, respiratory morbidity and growth among newborn infants in south india. International Journal of Epidemiology, 38: 1351-1363. Retrieved from http://ije.oxfordjournals.org/content/38/5/1351.abstract

Wilkinson, P., Smith, K.R., Joffe, M., and Haines, A. (2007). A global perspective on energy:

health effects and injustices. The Lancet, 370(9591): 965-978. Retrieved from http://ehs.sph.berkeley.edu/krsmith/?p=386

Obesity: Paradox of a Country Plagued by Malnutrition

India is a country plagued by paradoxes.  While there is a booming IT and technology sector there is still a 30% illiteracy rate.  Women have had positions of power throughout history including the seat of Prime Minister and yet women are still discriminated against and have little power over their own lives.  The country is plagued with malnutrition and yet there is a rising obesity rate.  It is difficult for a government to care for the problems of over 1 billion people when there are such contrasting issues.  Yet obesity rates are in issue that should not be ignored considering the rapid rise and various health affects that obesity causes. 

Malnutrition is often the leading issue when it comes to discussions of health and nutrition.  However, India is now seeing a rise in the prevalence of obesity, especially in Indian women.  According to the 2005-2006 National Family Health Survey 14.8% of ever married women between the ages of 15-49 are obese compared to 12.1% of males.  Interestingly, women suffer a double burden from also having a higher rate of malnutrition.  The National Family Health Survey reported that 33% of women were below normal on the Body Mass Index compared to only 28.1% of males.  This is a fascinating phenomenon because it would seem that obesity rates would be more prevalent among men because they are often the ones that eat first and receive the best foods due to various cultural habits.  However, there have been many studies on this issue that have uncovered various reasons as to why obesity is more prevalent among women and the effects that it has on their health.

Overall obesity rates seem to have risen due changes in the nature of work and transportation and the increased consumption of energy dense processed foods (Subramanian, Kowachi, Smith, 2007).  Urbanization of India has also led to increase levels of sedentary lifestyle because the activity of choice is often watching television (Shetty, 2002).  India seems to be following the pattern of other developed nations where the majority of the working population does not walk to school, commercials are encouraging diets filled with processed foods, and thus diets have become richer in fats.  However, the class of people that consume a diet of higher fat content is not the lower classes but rather the higher income class.  It has been shown that higher income groups consume a diet with 32% energy from fat while lower income groups consume only 17% energy from fat (Subramania, Perkins, and Khan, 2009, 373).  This is most likely due to the fact that those of higher incomes have enough resources to more than meet their caloric requirements of the day while lower incomes barely have enough resources to meet their daily needs.  This maldistribution of resources and food reveals problems within the country indicating inefficient public distribution and extreme income inequality. 

While the prevalence of obesity has risen for both men and women, women have been the most affected.  There is a 2% bigger rate among women than men and the rate has continuously been growing.  Obesity is most prevalent among women ages 40-49, living in urban areas, with high education, belonging to the Sikh community, and having a higher income (Garg, Shan, Ansari, and Garg, 2009).  The reason for higher obesity rates among older women may be due to the fact that older women have less energy expenditure and altered metabolic rates.  Obesity within Sikh communities may be a factor of the culture because women have less freedom to travel. 

There are higher health risks associated with obesity in men than women which makes the prevalence extremely troubling.  Studies done in Bombay show that obesity is associated with hypercholesterolemia, hyperlipidaemia, diabetes, and cardiovascular disease.  There are also higher abortion rates among obese women due to medical and surgical complications of pregnancy (Garg, Shan, Ansari, and Garg, 2009).   Not only does obesity affect the birth of infants but it affects their health following birth.  Childhood obesity risks are somewhat tied to parental obesity which then affects the child’s adulthood obesity rates.  Currently about 1% of preschool aged children are obese (Shetty, 2002).  The high prevalence of obesity among children coupled with higher birth weight also puts children more at risk for diabetes.

With a country that is plagued by poverty it is interesting to see the rise of obesity rates coupling the high amounts of malnutrition.  Not only is the fact that obesity rates are rising fascinating but women are the ones who are being affected by both malnutrition and obesity.  This trend speaks largely to the problems existing in India, mainly the problem of misdistribution of food and extreme income inequality.  It is difficult for any nation to formulate a nutrition plan that addresses both problems and to have the resources to deal with both issues.  India has largely focuses on malnutrition but it is equally as important to deal with obesity rates due to the various health issues it creates and the issues it creates for offspring of obese parents.  The mass media and the governments have to start educating the public about healthy diets so that as more people rise out of poverty the obesity rates do not increase even more, thereby placing further pressure on the health system in India.

References:

Garg, D., Khan, S.A., Ansari, S.H., and Garg, M. (2009). Prevalence of obesity in indian women.

Obesity Reviews, 11: 105-108. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19793374

Shetty, P. S. (2002). Nutrition transition in india. Public Health Nutrition, 5(1A): 175-182.

Subramanian, S.V., Perkins, J.M., and Kahn, K.T. (2009). Do burdens of underweight and

overweight coexist among lower socioeconomic groups in india. American Journal of Clinical Nutrition, 90: 369-376. Retrieved from http://www.ajcn.org/content/90/2/369.full.pdf

Subramanian, S.V., Kawachi, I., and Smith, G.D. (2007). Income inequality and the double

burden of under- and overnutrition in india. Journal of Epidemial Commmunity Health, 61: 802-809. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660005/

National Family Health Survey. (2009) Key indicators for india from NFHS-3. Retrieved from

http://www.nfhsindia.org/pdf/India.pdf

Poverty and the Prevalence of Arsenicosis

Poverty is ramped throughout India and is a main indicator of many factors such as quality of life, access to health care, education, per capita income, and access to improved sanitation.  However, living in poverty can also be linked to a higher risk and prevalence of various illnesses such as arsenicosis.  Arsenicosis is a chronic disease caused by contamination of arsenic usually through drinking water or contaminated food products.  Arsenic poisoning causes melanosis, keratosis, and many different breathing problems.  Contamination is partially due to over exploitation of groundwater which has led to leaching of the arsenic into the irrigation and drinking water sources.  One of the first cases of arsenic poisoning in India was in West Bengal in 1983 (Sarkar, 2009).  Since the first case of arsenic poisoning, the number of people at risk for arsenic poison increases annually.  This endemic is confined in India to the areas around West Bengal and Bangladesh

Retrieved from http://gangajal.org.in/blog/wp-content/uploads/2010/02/arsenic_map_of_asia.jpg

However, this area is a major agricultural zone and these areas transport a lot of their foods throughout India.  If the food is irrigated with contaminated water or processed with contaminated water those whom receive food from this area are just as much at risk (Sarkar, 2009).  This is why the problem of arsenicosis is a problem for all of India.

            Poverty is linked to the prevalence of arsenicosis for many reasons.  Once such reason is that there is a strong link between dietary intake and manifestations of chronic arsenicosis.  People with low intake of proteins and other macronutrients such as calcium, selenium, vitamins A, C, and E are more prone to arsenic related diseases (Sarkar, 2009).  Many of these nutrients come from pulses but production of pulses in West Bengal has declined from .24 million tones in 1980 to .17 million tones in 2003 and due to the shrinking supply the poor cannot afford these types of foods (Sarkar, 2009).  These pulses are important because without them the body has a slower metabolism, less detoxification in the liver and impaired urinary elimination of arsenic (Sarkar, 2010).

Once rural villagers develop the disease they are worse off than those of higher socioeconomic status because they are in areas with poor infrastructure and limited medical care.  This disease often affects their physical abilities which further reduces their economic activity and spirals them into a lower poverty level.  One study was done in Bangladesh looking at 5 villages where arsenic contaminated existed in 2005.  In Bangladesh overall 103 million people are dependent on shallow wells and more than half of the population is at risk for high levels of arsenic.  Specifically in these five villages they found a high correlation between literacy, poverty, and arsenic concentrations.  In Rajarampur there is low female literacy, high poverty, and has 14 contaminated wells.  However, Ranihati has the same percentage of poverty but has 35 contaminated wells.  This disparity may be explained by the fact that Ranihati has a slightly larger number of members per household so each member receives a lesser share of nutrition in their diet (Nahar, Hossain, and Hossain, 2008, 44).  Villagers in this area with a lower per capita income were also more likely to incur arsenicosis due to this low diet.  This study clearly shows the correlation between poverty and risk of arsenicosis. 

The question remains, what can be done about this situation?  There are multiply possible solutions such as rainwater harvesting, filters, due wells, and improving medical care.  Governments and international organizations have usually pushed filters because they are inexpensive.  However, the filters produce a toxic sludge that must be disposed of and often times the filters do not receive the proper maintenance required.  Organizations have to look at each individual village and see what works for them specifically.  Many villagers even if they receive filters do not use them because of a choleric smell.  Perhaps the most beneficial solution might be to provide better access to medical care for those of lower socioeconomic status.  People with higher socioeconomic status have greater access to information and can afford alternative services.  Poor villagers on the other hand are more likely to seek care from untrained health workers (Sarkar, 2010).  The best solution would to provide villagers with better roofing material so that rainwater harvesting could be a viable option.  However, this is an expensive endeavor and not completely viable.  The best option as of right now seems to be increasing knowledge and understanding about the risks of arsenic contamination and providing proper medical care.

References

Nahar, N. , Hossain, F. & Hossain, D. (2008). Health and socioeconomic effects of groundwater

arsenic contamination in rural bangladesh: new evidence from field surveys . Journal of

environmental health, 70(9), 44-47. Retrieved from http://iweb.tntech.edu/fhossain/papers/HealthArsenic_review.pdf

Sarkar, A. (2010). Ecosystem perspective of groundwater arsenic contamination in india and

relevance in policy. Ecohealth, 7, 114-126. Retrieved from http://www.springerlink.com/content/n107p165j14374m4/

Sarkar, A. (2009). Sustainable solutions to arsenic contamination of ground water: a review of

existing opportunities in the ganga-meghna-brahmaputra basin. (pp. 72-87). New Delhi, India: Water, Agriculture and Sustainable Wellbeing Oxford University Press.

Ensuring Maternal Health- More than just a Vehicle for Ensuring Child Health

The field of maternal and child health has largely been focused on child health and how maternal health influences child health.  It is a huge mistake for international agencies to view maternal health merely as a vehicle to ensure a child’s health rather than seeing maternal health as innately beneficial.  Women in developing countries are responsible for producing 3/4ths of the food and are often the key indicators for family health for generations.  Women are vital to a society’s functioning and prosperity, yet maternal health is often tossed aside as an additional benefit to reducing infant mortality.  Not only is maternal health not given enough attention, but when it does receive attention the focus is often on improving facility access. However, ensuring maternal health is not about simply reducing maternal mortality by providing to an adequate facility and deliver in the presence of a trained attendant. 

Maternal health is about all the factors that go into a mother’s pregnancy, the habits and environment surrounding her pregnancy, and the overall health of the mother after delivery.  To deal with maternal health both social and environmental factors have to be analyzed. Social factors influencing maternal health include as discrimination, social status, poverty, and education and environmental factors.  Environmental factors include quality of water, quality of diet and access to proper nutrients, air pollution, and basic exposure to the elements.  These environmental factors are often reflective of a mother’s status especially poverty.  A woman in poverty is much more likely to be negatively exposed to such environmental factors than a rich woman who has better access to quality food and water and improved sanitation. 

The biggest contributor to maternal health is hemorrhaging, which contributes to 38% of all maternal deaths in India.  Hemorrhage occurrences can be reduced with increased access to facilities but mothers still need to have the funds to pay for such access and many mothers cannot afford to go to hospitals, thus poverty plays a huge factor in access to health care.  While hemorrhage is the biggest contributor to maternal death, conditions like sepsis, hypertensive disorder and other conditions like anemia make up over 50% of all deaths (Vora et. al., 2009).  Sepsis and various other conditions are largely due to environmental factors that are also caused by social issues like poverty and social status.  Sepsis is a bacterial infection that can occur from open wounds; people with low immune systems are the most highly at risk (Sepsis, 2010).  Impoverished women are constantly in contact with poor sanitary conditions that are breeding grounds for bacteria and often times when a women gets a cut she is not going to seek care.  Sepsis can be a life threatening disease that could be prevent by simply providing women with access to improved sanitary conditions. 

Maternal health could be increased by focusing on three specific factors: literacy rates, fertility rates, and age of marriage.  All three of these factors indicate a gain in education which translates into a gain in health because women learn why and how to eat nutritious foods, why sanitation is important, and are becoming empowered so that they can seek a paying job.  Allowing women to hold a paying job is significantly important for a family because a woman is much more likely to spend her money on her family’s overall health and well being.  If a woman is able to feed her and the family the proper nutrients needs, there is less of a chance that the mother will die in labor due to maternal depletion syndrome.  Education will also allow a woman to understand the consequences of not going to an institution to give birth.  A study showed that in India only 18% of illiterate mothers had institutional deliveries compared to 86% of mothers with 12 or more years of education (Vora et. at., 2009).  Many women in India are not fond of government sponsored facilities so if they cannot afford a private facility they will opt for a home delivery which is much more dangerous.  Perhaps with an education women will be more likely to accept care at a government facility because they will understand the implications of not seeking care. 

India is accounted for at least 1/4ths of all maternal deaths with 301 deaths per 100,000 live births (Vora et. al., 2009).  While maternal deaths are high for India as a whole, there is regional variation that reflects on how various factors influence maternal mortality.   Southern India has a much lower maternal mortality rate than the north which may be attributed to higher female literacy rates, lower fertility rates, and a higher average age of marriage.  Tamil Nadu is located in the southern region and has a fertility rate of 1.7, a mean age of marriage at 22 and a female literacy rate of 64.4%.  All o f these factors contribute to its maternal mortality rate of 134 deaths per 100,000 live births (Vora et. al., 2009).  In contrast, Rajasthan is in the northern region of India and has a fertility rate of 3.7, a mean age of marriage at 20 and a female literacy rate of 43.8%.  The maternal mortality rate for the state is much higher than the average for India at 445 maternal deaths per 100,000 live births (Vora et. al., 2009).  In achieving maternal health it is possible that fertility rates will go down as well, placing much less of a burden on society and families in developing countries. 

Changing fertility rates can also reduce maternal deaths by reducing the proportion of high risk deliveries (Koblinsky et. al., 2008).  For example, in Bangladesh the total fertility fell by 3.6 children from 1970 to 2004, which corresponded to the reduction in the number of pregnancies which placed women at the risk of maternal death.  Research also showed that risk of maternal mortality reduced for births 1-3 from 1976-2005 when various program were introduced to reduce maternal mortality but after the 3^rd birth the risk of death did not decrease with any of the factors.  This shows that reducing fertility is essential in reducing maternal mortality.  

Maternal health is a very complex issue that involves various social and environmental factors.  Maternal health and maternal mortality cannot be cured by focusing on one aspect; the issue of maternal health needs to be viewed in a comprehensive manner.  Political parties, international organizations, communities, and governments do not give maternal health the proper attention that it deserves considering all the effects that it has on not only infant mortality but overall family and societal health.  Communication has to be increased throughout these groups to increase understanding about both the complexities and the importance of dealing with maternal health.  

References

Koblinsky, M., et al. (2008). Reducing maternal mortality and improving maternal health: Bangladesh and mdg 5. Journal of Health, Population, and Nutrition, 26(3): 280-294. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740701/

Sepsis. (2010). A.d.a.m. medical encyclopedia. Retrieved September 1, 2011, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001687/

                Vora, K., et al. (2009). Maternal health situation in india: a case study. Journal of Health, Population, and Nutrition, 27(2): 184-201. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19489415