Prevalence of reproductive health issues and knowledge, attitude, and practice of personal protective equipment use among women working in the fireworks industry: A cross-sectional study.

Birth defects are structural or functional abnormalities, including metabolic disorders, present from birth. Irrespective of definition, birth defects can cause spontaneous abortions (miscarriages) and stillbirths and are a significant but under-recognized cause of mortality and disability among children under 5 years of age.[ 1 ] According to the March of Dimes (MOD) global report on birth defects, 7.9 million births (6% of total births) occur annually worldwide with serious birth defects and birth defects cause about 14 percent of stillbirths.[ 2 ] A stillbirth is the death or loss of a baby after 28 weeks of pregnancy before or during delivery.[ 3 ] The study significantly contributes to public health and occupational health fields by addressing an under-recognized yet critical issue of reproductive health risks among women in the fireworks industry. According to the World Health Organization (WHO) and the MOD report, birth defects account for 7% of neonatal mortality and 3.3 million under-5 deaths globally.[ 4 ] In India, the congenital birth defects prevalence is 25 per 1000 live births.[ 5 ] Environmental and maternal causes are responsible for an estimated 4% to 10% of congenital anomalies also known as birth defects.[ 6 7 ] Numerous literature studies show that maternal exposure to harmful chemicals is a significant cause of birth defects.[ 8 ] A limited number of studies have been done in the fireworks industry. Fireworks are made of a pyrotechnic chemical capable of emitting heat, light, sound, and gas on ignition The chemicals used in the manufacture of fireworks are aluminum powder, magnesium, potassium nitrate, barium nitrate, barium carbonate, strontium nitrate, sodium nitrate, sulfur, iron chips, red phosphorus, lead oxide, charcoal, dextrin, hexamine, polyvinyl chloride (PVC), and so on.[ 9 ] These chemicals are hazardous [ Table 1 ]. Chemicals used in fireworks and their side effects This study uniquely explores the prevalence of reproductive health issues, including stillbirth, miscarriage, and birth defects, among women employed in the fireworks industry. It provides novel insights by linking occupational chemical exposure to adverse reproductive outcomes, emphasizing the occupational risks faced by this vulnerable group. Unlike prior studies, this research identifies specific associations between prolonged chemical exposure and health outcomes and highlights the critically low usage of personal protective equipment (PPE) due to systemic deficiencies in workplace safety measures. The study’s findings address a critical knowledge gap and propose actionable strategies for improving occupational safety and reproductive health. The fireworks industry is well known to be a hazardous industry. About 90% of Indian fireworks industries are situated in Sivakasi, Tamil Nadu.[ 10 ] Certain chemicals used in the manufacture of fireworks have a risk of birth defects and stillbirth.[ 11 ] According to the District Human Development Report 2017, the highest stillbirth rate is witnessed in Sivakasi (15.0) of Virudhunagar district.[ 12 ] The current research is highly pertinent to primary care physicians, who are often the first line of defense in identifying and addressing health concerns among women in hazardous occupations. The study equips physicians with critical knowledge to identify reproductive health issues related to occupational exposure and raise awareness about the risks of chemical exposure and the importance of using PPE. These roles are integral to mitigating the reproductive health risks uncovered in this study, ensuring better health outcomes for this high-risk population. In this context, our study was designed to study the prevalence of birth defects, stillbirth, and miscarriage among women working in the fireworks industry. To assess the knowledge, attitude, and practice of PPE use among women working in the fireworks industry.

The study participants were only women working in the fireworks industry. The mean age of study participants was 37, with a minimum age of 20 and a maximum age of 59. The majority of the participants, 289 (96.3%), were Hindu, and most of them, 271 (90.3%), belonged to the Scheduled Castes (SC) category. The mean age at marriage of study participants was 19 years. Out of 300 participants, 105 (35%) participants were married consanguineously and 195 (65%) were married nonconsanguineously [ Table 2 ]. Distribution of study participants in sociodemographic characteristics ( n =300) With regard to educational qualification, 128 (42.7%) of participants had no formal education, while 83 (27.7%) had attended middle school and 70 (23.3%) had a primary level qualification. The predominant income category is 100–200 rupees per day, where 213 (71%) of participants fall under this category, and only 6 (2%) of participants earn 301–400 rupees per day. Most of the study participants’ husbands’ occupations were also in the fireworks industry 161 (53.7%) and 45 (15%) of participants’ husbands were construction workers [ Table 2 ]. Out of 300 workers, the prevalence of stillbirth was 8.3%, Miscarriage was 22%, and birth defect was 2%. The types of birth defects among those (n = 6) were congenital heart disease, 66.7%, and mental retardation, 33.3%. Almost 99.7% of women worked in the fireworks industry even during pregnancy, and 80.4% worked for more than 6 months of gestation. About 98.3% of women remained in the same work during pregnancy; others changed to other types of work in the fireworks industry. Among 299 women who worked during pregnancy, 79.6% of women worked with direct exposure to chemicals in the fireworks industry [ Tables 3 and 4 ]. Work and Pregnancy ( n =300) Work and Chemical Exposure The family history of the participants was collected along with their occupations. Results revealed that among the family members with a history of birth defect (n = 29), 69% of people are working in the fireworks industry, and among the family members with a history of stillbirth (n = 36), 86.1% of people are working in the fireworks industry. Pearson’s Chi-square test was performed to understand the association. The P value (0.028) is less than 0.05, showing there is an association between years of exposure and occurrence of stillbirth. The odds of stillbirth among women workers with exposure of more than 19 years to chemicals were 2.58 times higher than among women workers with exposure of less than 19 years to chemicals. Later results were that stillbirth, birth defect, and miscarriage have no association with age of marriage, consanguinity of marriage, family history, or complications of labor which all are risk factors, which shows that there is more possibility that stillbirth, birth defect, and miscarriage can be caused due to chemical exposure. The workers reported oral health issues such as mouth ulcer, gingival bleedings, oromucosal lesion, skin allergies, eye irritation, and respiratory symptoms due to direct exposure, followed by body pain and hip pain due to prolonged sedentary posture and manual work [ Table 5 ]. Other health issues due to work Among individuals knowledgeable about PPE, the primary reason for not using PPE was that it was not provided by the workplace (69.5%). Other reasons included discomfort while using it (23.7%), a perception that PPE was not compulsory (3.4%), and the belief that it was unnecessary for their work (3.4%) [ Figure 1 ]. Reasons for not using personal protective equipment among knowledge people during working (n = 59) For those knowledgeable about wearing only cotton clothes, the most common reason for not following this practice was that it was not compulsory (35.4%), followed by the lack of provision by the workplace (29.2%). Additional reasons included washing difficulties (18.5%) and discomfort while wearing cotton clothes (16.9%). This highlights a significant gap in the provision and enforcement of protective measures in the workplace [ Figure 2 ]. Reasons for not wearing only cotton clothes among knowledge people during working (n = 130) Most respondents claimed that the industry offered no PPE. Even though the same reasons apply to wearing only cotton clothes, the major reason was it is not a compulsory rule in the industry to wear only cotton clothes for work.

In the present study, the prevalence of miscarriage is 22%, that of stillbirth is 8.3%, and that of birth defect is 2% among women working in the fireworks industry. This is the first study done in the fireworks industry only among women to study the prevalence of stillbirth, birth defects, and miscarriage due to exposure to chemicals in the fireworks industry. Sivakasi’s fireworks industry poses unique risks, including chemical exposure, fire hazards, inadequate safety measures, and pollution. Women face reproductive health risks, and child labor persists in some areas, highlighting significant health and safety challenges. Dhruv Katoria et al .[ 13 ] study discussed the risks to workers associated with the fireworks industry in Sivakasi. The author generally reviewed the risks of chemicals in the fireworks and fireworks industry rather than specified risks or diseases. These harmful effects of chemicals and other chemicals are discussed in this study in Table 1 . The majority of the women laborers in the fireworks industries in Virudhunagar district are predominantly facing joint pain, skin problems, back pain, abdominal pain, difficulty in swallowing, and pain in the genitals.[ 14 ] A study revealed that 78.8% of the women workers had mild body pain due to prolonged working hours, 81.2% of the women workers had breathing problems, 50% of the respondents had a headache, and 85.5% of the respondents had mild mental illness strain due to stress.[ 15 ] Some of the common health issues of Sivakasi citizens were asthma, allergic bronchitis, emphysema, COPD, headache, skin, and eye irritations. These results coincide with health issues reported orally by the women workers in this study. Skin allergies are present in 4.3% of women, eye irritation in 4%, respiratory symptoms in 2.7%, headache in 1.7%, back pain in 5.3%, abdominal pain in 2%, and joint pain, including hip pain and leg pain in 5.7% of the women workers. Sophia Porchelvi et al. ,[ 16 ] in their study conducted in Virudhunagar District among the people working in the fireworks industry, reveal that due to the direct contact with hazardous substances, people working in that industry were facing some major health issues like lead poisoning, ulcers, and damage to the central nervous system. Also, she stated that people are exposed to these risks right from the initial stage of manufacturing, storage, and transportation, in which their risk to life and property becomes high. The study also suggested providing proper training and awareness on the risk of chemicals they use, personal hygiene, and proper protective equipment. This is explained in this study where only 20.7% of the women have knowledge about PPE, and among them, only 4.8% of women use PPE while working. In the review article of Ajith et al. ,[ 17 ] 89% of the workers were unaware of the hazardous chemicals, 92% of the workers said no proper training sessions were conducted before they started any task, and 97% of the workers reported that the management provided no safety tools during work. In the study of industrial safety and wellbeing of fireworks employees in Sivakasi, 56.7% of the respondents said that there are no safety guards around the machine, and the majority of respondents feel that they need proper safety materials like gloves to mask while they are handling chemicals, and they also said that they need a proper medical checkup for once in 6 months.[ 18 ] From the current study, it is known that 95.8% of women workers said that they do not wear any PPE while working, and among them, 69.5% of women reported that the management does not provide PPE during work. As discussed in Table 1 , chemicals like cadmium, lead, potassium perchlorate, and polyvinyl chloride have effects like birth defects, stillbirth, and miscarriage. When women are exposed to these chemicals, they might end up in any of these effects. Our results showed an association between years of exposure and stillbirth, where the P value (0.028) was less than 0.05, which was significant. Also to ignite the key result, further analysis shows that stillbirth, birth defect, and miscarriage have no association with age of marriage, consanguinity of marriage, family history, or complications of labor, which all are risk factors, showing that there are more possibilities that stillbirth, birth defect, and miscarriage can be caused due to chemical exposure. From the results, it is also known that only 4.8% of people use PPE among 20.7% of knowledgeable people. It was also clearly seen that almost 99.7% of women worked in the fireworks industry even during pregnancy, with 79.6% working with direct exposure to chemicals. Thus, it can be concluded that pregnant women are being exposed to chemicals in the workplace because workers are not wearing PPE.

According to the World Health Organization (WHO), primary infertility rates in India range from 3.9% to 16.8%. Such pregnancies are exacerbated by stillbirth, miscarriage, and pregnancies with birth defects. Avoiding direct exposure to chemicals during pregnancy and allowing for a shift to a job with no or minimal exposure to chemicals are the best ways to reduce these burdens. Most workers are uneducated and from SC. PPE should be provided to pregnant women and all workers to prevent diseases. All workers should be aware of the hazards of the chemicals used in the fireworks industry and the proper use of PPE through proper training and meetings. Effective health education initiatives along with ongoing counseling can help people develop positive outcome. The study focuses on women in the high-risk fireworks industry, gathering comprehensive data on occupational exposure and PPE practices using a semistructured questionnaire. It provides valuable real-world insights through both quantitative and qualitative data, supporting targeted safety interventions. Ethical compliance, ensured through informed consent, adds to the study’s credibility. Key interventions for Sivakasi include mandatory PPE distribution, regular safety training, and strict enforcement of workplace safety laws. Additional measures include periodic health checkups, awareness campaigns on occupational risks, improved workplace infrastructure, independent safety monitoring, and targeted support for women workers’ health and safety. The study’s limitation lies in estimating the prevalence of stillbirth, miscarriage, and birth defects based on self-reported data, which may be subject to recall and social desirability bias, as women may withhold information on emotionally charged topics. The focus on women in the Sivakasi fireworks industry limits generalizability to other populations, and sampling bias could occur if informal laborers are underrepresented. Future research could include a control group and laboratory investigations to enhance accuracy and generalizability. The current study was approved by the Institutional Ethical Committee (IEC) of SRM School of Public Health, SRMIST, Kattankulathur, and Tamil Nadu. Data and study information were gathered after obtaining informed consent. There are no conflicts of interest.

The study was conducted in Sivakasi, Virudhunagar district of Tamil Nadu. The study was undertaken in nine villages, namely, Uraampatti, Maniyampatti, Chinnapottalpatti, Subramaniyapuram, Ammapatti, Periyapottalpatti, Kamarajar colony, and Eswaran colony. A descriptive cross-sectional design was chosen for this study because it allows for a snapshot of the prevalence of reproductive health issues (such as miscarriage, stillbirth, and birth defects) among women working in the fireworks industry. This design is appropriate for assessing the prevalence of health outcomes and the knowledge, attitudes, and practices (KAP) related to PPE use at a specific point in time. The estimated sample size of the study was 284, with the prevalence of birth defects due to chemical exposure at 4%,[ 13 ] with a confidence interval of 90%, an error of 2%, and a nonresponsive rate of 10%. A nonprobability convenient sampling method was used to obtain the samples. The inclusion criteria for the study were as follows: married women who had been working in the fireworks industry for a minimum of 1 year and women who had worked in the fireworks industry during their pregnancy. Participants had to be willing to engage in the study and provide informed consent. Women were excluded from the study if they met any of the following conditions: They had not been employed in the fireworks industry during their pregnancy. Women who had not worked in the fireworks industry for at least one year were also excluded. Additionally, women who were unwilling to participate or provide informed consent were excluded. A semistructured questionnaire was developed to collect data on participants’ demographic characteristics, medical and obstetric history, exposure to chemicals, and knowledge, attitude, and practices (KAP) regarding PPE. The tool was pretested with a small sample to refine its clarity. Reliability was assessed using Cronbach’s alpha, achieving a score above 0.7, ensuring internal consistency. Validity was established through expert consultations and a pilot study, confirming the tool accurately measures the intended concepts. Adjustments were made based on feedback to enhance the questionnaire’s reliability and validity. The data collected from the study were entered and coded in Microsoft Excel and subsequently exported to IBM SPSS Statistics (trial version 22.0, IBM Corp., Armonk, NY, 2015) for analysis. Descriptive statistics were applied to calculate the proportions of key variables within the population, including the prevalence of adverse reproductive health outcomes and the knowledge, attitude, and practice (KAP) regarding the use of PPE.