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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 26-35

An observational study on health-related demography of women and children belonging to scheduled caste population in selected areas of Thiruvananthapuram district of Kerala state, India

1 Regional Ayurveda Research Institute, Thiruvananthapuram, Kerala, India
2 M S Regional Ayurveda Research Institute, under Central Council for Research in Ayurvedic Sciences, New Delhi, India
3 Central Council for Research in Ayurvedic Sciences, New Delhi, India
4 National Ayurveda Research Institute for Panchakarma, Cheruthuruthy, Kerala, India
5 Department of Salakyatantra, Banaras Hindu University, Varanasi, India

Date of Submission29-Jul-2021
Date of Acceptance13-Sep-2021
Date of Web Publication14-Dec-2021

Correspondence Address:
Dr. Sinimol T Peethambaran
Regional Ayurveda Research Institute, Thiruvananthapuram, Kerala.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jras.jras_34_21

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BACKGROUND: The scheduled caste (SC) population of India, especially women and children, lags behind others in the health scenario and the problem should be addressed with emergency concern. AIM: The aim of this article is to describe the health-related demography of women and children of SC population in selected areas of Thiruvananthapuram district of Kerala state, India during the year 2019. MATERIALS AND METHODS: The Reproductive and Child Health project team of Regional Ayurveda Research Institute for Lifestyle-Related Disorders, Thiruvananthapuram conducted health camps at four village panchayaths (village councils), namely, Maranalloor, Venganoor, Vilappil, Poovachal, and Neyyattinkara municipality of Thiruvananthapuram district, Kerala through 240 tours during the period January to December 2019 through a door-to-door household survey for collecting the information on socio-economic and health status. Medical aids were also provided to needy individuals. RESULTS: A total of 5145 individuals were surveyed, which includes 3662 women and 1483 children. In the survey, 62 disease conditions in women and 25 various disorders in children were diagnosed. The most common clinical manifestation found in women and children was Sandhigatavata (polyarthritis) and Agnimandya (digestive impairment), respectively. CONCLUSION: The women and children belonging to SC population in the areas of Thiruvananthapuram district where study was conducted have good health status. However, considering the prevalence of polyarthritis in women and digestive impairment in children, diet and lifestyle related-vigilance needs to be promoted. Ayurveda includes noteworthy guidelines regarding personalized as well as season-based diet and lifestyle. Therefore, increasing vigilance in rural population toward such Ayurveda guidelines along with use of relevant Ayurveda medicines can be a strategy to improve the health status of women and children. IEC number: 9–19/2012-ARIMCHC/Tvpm/Tech/220

Keywords: Children, health demography, India, Kerala, scheduled caste, Thiruvananthapuram, women

How to cite this article:
Peethambaran ST, Meghna PP, Gavali K, Ota S, Shahi V, Devarakonda S, Srikanth N, Dhiman KS. An observational study on health-related demography of women and children belonging to scheduled caste population in selected areas of Thiruvananthapuram district of Kerala state, India. J Res Ayurvedic Sci 2021;5:26-35

How to cite this URL:
Peethambaran ST, Meghna PP, Gavali K, Ota S, Shahi V, Devarakonda S, Srikanth N, Dhiman KS. An observational study on health-related demography of women and children belonging to scheduled caste population in selected areas of Thiruvananthapuram district of Kerala state, India. J Res Ayurvedic Sci [serial online] 2021 [cited 2023 Jun 5];5:26-35. Available from: http://www.jrasccras.com/text.asp?2021/5/1/26/332442

  Introduction Top

In order to improve the health status among rural population, various programs such as National Rural Health Mission (NRHM) were implemented by the Government of India in due course of time. Programs related to maternal and child health include Family Planning during 1960–1970, Immunization during 1970–1980, and National Diarrhoeal Diseases Control Programme during1980–1990. These programs were fragmented and inconsistent until the beginning of the NRHM in 2005. To bring about those things required to promote child and women health, the imperfect health systems and minimal budget for health existed at that time were not sufficient. Consequently, many targets in this regard were not achieved by India.

In 1992, India created the Child Survival and Safe Motherhood Programme (CSSM) for bringing together programs for child survival (essential new-born care, immunization, the National Prophylaxis Programme against Vitamin A Deficiency-induced Nutritional Blindness, control of acute respiratory infections, diarrheal disease) and health of mothers (institutional delivery, antenatal care, obstetric treatment during emergency). By merging CSSM and the programs for family planning, Reproductive and Child Health (RCH) Programme was launched in 1997. Institutional deliveries and obstetric treatment during emergency as the vital strategy for decreasing mortality rate of mothers became the emphasis of RCH program.[1]

For achieving the targets of reducing maternal and child mortality and total fertility rates, RCH program was launched underneath the broader umbrella of NRHM, which is currently a part of National Health Mission. Reduction of social and geographical disparities in access and utilization of quality reproductive and child health services are the main objectives of this comprehensive flagship program.[2]

Overview of scheduled caste (SC) population of Kerala state

The SC population in Kerala state is 3,039,573, which constitutes 9.10% of the whole population according to the 2011 population census. Compared with other states in India, the settlement pattern of SC in Kerala is completely dissimilar. In Kerala, most of them live along with other people in a scattered manner. The Palakkad district (13.29%) has maximum distribution, followed by Thiruvananthapuram (12.27%), Kollam (10.80%), and Thrissur (10.67%) districts. Malappuram (10.14%) holds the fifth position. About 57.17% of the total SC population of Kerala lives in these five districts. The representation is about 10% of the whole population in Thiruvananthapuram. The most economically poor communities belonging to SC are the Vedar, Chakkaliar, Nayadi, Vettuvan and Kalladi.[3] They lag behind others regarding general health status. The life expectancy of SC population, constituting 16.5% of the population of India, is relatively low. They also have relatively high child and adult mortality rate. Children are more undernourished and about 50% of all maternal deaths in the country are attributed to them.[4]

As an apex body of research in Ayurveda, under the program SC Sub-Plan, Central Council for Research in Ayurvedic Sciences (CCRAS) is providing healthcare services and creating awareness for maintenance and promotion of health of SC community by Ayurvedic approaches through its different institutes across the country. The Reproductive and Child Health Care Programme (under SC Sub-Plan) was initiated by the Regional Ayurveda Research Institute for Lifestyle Related Disorders (RARILSD), Trivandrum on January 7, 2019.

Published studies on health-related demography of women and children of SC population in selected areas of Thiruvananthapuram district of Kerala so far are not available with sufficient details, except that some aspects are covered in census data and district health survey data. This paper deals with health-related demography of women and children belonging to SC in the five villages of Thiruvananthapuram district of Kerala state of India, namely, Maranalloor, Venganoor, Vilappil, Poovachal, and Neyyattinkara, collected through RCH program of RARILSD during the year 2019 [Figure 1].
Figure 1: Map of India, Kerala state and Thiruvananthapuram district

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The objectives of the study were creating awareness on importance of nutrition, hygiene, and prevention of diseases, especially lifestyle disorders and health promotion through behavior change counseling (BCC) by providing IEC materials; use of common medicinal plants available in the areas; screening of nutrition status, anemia, recurrent infection status in all SC children and their management through Ayurveda; providing primary healthcare services through health camps based on principles of Ayurveda especially to women and children of SC community; and propagation of knowledge about Ayurvedic concept of Pathyapathya (do’s and dont’s of food), Dincharya (Ayurvedic daily regimen), and Ritucharya (seasonal regimen).

  Materials and Methods Top

Study setting

Five villages of Thiruvananthapuram district, namely, Maranalloor, Venganoor, Vilappil, Poovachal, and Neyyattinkara, having majority of SC population as per the census 2011, in the vicinity of the institute were selected for the study considering the feasibility to visit these villages on daily up-down basis. Before initiation of the study, the Sarpanch/Grampanchayat (village council) member and other local authorities of these areas were informed about the project, viz., beneficiaries, benefits, and mode of implementation of the project. The consent of village authorities was taken to carry out the work. IEC materials and pamphlets were distributed for promotion and awareness of the project. The study was conducted between January 2019 and December 2019 with the approval of Institutional Ethics Committee. Ethical clearance number is 9–19/2012-ARIMCHC/Tvpm/Tech/220.

Details of five selected villages[5]

Maranalloor village has an estimated population of 35,610 people, of which 17,507 are males and 18,103 are females according to the 2011 census. The total area of the village is 25.13 km2. The SC population of the area is 5454, which includes 2812 males and 2642 females. Venganoor is a village which extends over an area of 13.8 km2. The village has an estimated population of 35,963 people, of which 17,728 are males and 18,295 are females. The SC population of the area is 6356, which includes 3136 males and 3220 females.

Poovachal is a village which extends over an area of 33 km‐. It has an estimated population of 43,610 people, of which 21,222 are males and 22,388 are females. The total SC population of the area is 3602, which includes 1751 males and 1851 females. Neyyattinkara is a municipality which has a population of 70,850 people; 34,513 males and 36,337 females are included in this. The total area is 28 km2. The total SC population of the area is 7772, which includes 3704 males and 4068 females. The total population of Vilappil village is 36,212. People of these areas speak Malayalam and only a very few are familiar with other languages. They use rice or wheat as part of their main meal. Pulses are also included. Most families use cow’s milk. They mostly depend on the public transport system. Education and health facilities are available in all villages.

Study population

About 5145 women of reproductive age (13–50 years) and children below 12 years belonging to SC population residing in these areas were selected.

Study tools

Structured questionnaires prepared by the CCRAS, Ministry of AYUSH, New Delhi, India were used for data collection.

Data collection

Selected villages were visited on a weekly basis for one year to survey the population and was carried out by means of structured formats for recording their sociodemographic and health status. During these visits, health checkup camps were organized to offer Ayurvedic treatment and advice. A project team comprising Ayurvedic physicians, social worker, laboratory technician, and multi-tasking attendant was engaged for this purpose. The village authorities were informed 2 days in advance about up-coming visit of the team to their village for spreading awareness about the visit, and any cancellation of the tour due to unavoidable circumstances was also informed to the village authorities well in advance.

Depending on the population (SC) and size of the village, the annual tour plan/schedule was planned. The study team visited SC households of identified villages to collect the data of eligible population. Face-to-face interviews were conducted for the same. The collected information includes (i) village/area information, (ii) house information such as type of house, ventilation, drinking water source, drinking water purification method, toilet facilities, method of vector-borne disease prevention, drainage facility, etc., (iii) sociodemographic data, viz., age, sex, marital status, education, occupation, dietary habits, addiction, etc., (iv) personal health information of women such as menstrual history, obstetrical history, contraceptive history, etc., (v) health-related information of children, viz., immunization status, school-going status, any recurrent common childhood infections such as respiratory/gastrointestinal/dermatological infections, and growth and development appropriate to age or not. Investigations like Hb gm% and blood sugar levels were carried out during the camp.

Data analysis

It was an observational study, so that the qualitative data have been presented in number and percentage.

  Results Top

The data of 2522 houses and sociodemographic data of 5145 SC population (3662 women and 1483 children) were collected through a door-to-door survey and personal interviews. Clinical data of 4887 patients (which includes 4679 women and 208 children), who were given treatment at the healthcare camps, were collected in the designed data collection format. The patients were from surveyed population and also from other non-surveyed population.

Status of basic house facilities in the selected five villages

As far as the status of the basic facilities of the 2522 surveyed houses in the villages are concerned, 1185 (46.78%) of the houses were RCC type, 554 (21.97%) were kaccha type, 581 (23.04%) were pukka houses, and 202 (8.01%) were thatched house. Adequate ventilation facility was observed in most of the houses, 2465 (97.74%). People of 2005 (79.5%) houses used well, 504 (19.98%) used tap, 11 (0.44%) used hand pumps, and 2 (0.08%) used springs as source of drinking water. About 2519 (99.98%) homes used boiled water for drinking; 2509 (99.48%) of the surveyed population had toilet facility (either inside or outside of the house). Regarding drainage facility, 1336 (52.97%) had closed type; 2519 (99.88%) homes used some or other types of methods for vector-borne disease prevention. LPG was used as fuel for cooking in 2209 (87.59%) and wood in 253 (10.03%) houses.

Distribution of population surveyed

Of the 5145 population surveyed, 3662 (71%) were women belonging to 13–50 years of age and 720 (13.99) were male children <12 years and 763 (14.83) were female children <12 years.

Demographic status of SC women of age 13–50 years

Of the 3662 women surveyed, 2629 (71.8%) were married, 821 (22.4%) were unmarried, 174 (4.75%) were widowed, and 174 (1.04%) were divorced/separate. As far as educational status is concerned, only 33 (0.9%)were illiterate, 2031 (55.46%) had school education, 728 (19.9%) had intermediate education, and 870 (23.75%) were even having education level equal to or above graduation. Regarding the occupational status, 2138 (58.38%) were housewives, 616 (16.82%) were students, 377 (10.29%) were in government/private service, and 531 (14.51%) were engaged in other skilled/unskilled labor. About 3639 (99.37%) used non-vegetarian diet. Only 1 (0.03%) had addictions of tobacco/pan masala or alcohol. About 3500 (95.58%) consulted allopathic system of medicine, 59 (1.61%) consulted Ayurveda, 75 (2.05%) consulted homeopathy, and 28 (0.77%) consulted other systems of medicine for primary management of various disorders.

Menstrual history data of women between ages 13 and 50 years and obstetrical history of surveyed women

Regarding menstrual history of the 2874 women who had not attained menopause, 2644 (92%) women had regular menstrual cycles [Table 1]. The number of abortions was 60 (0.99%) and there was only one (0.02%) stillbirth. About 5971 (99.97%) had hospital deliveries [Table 2].
Table 1: Menstrual history data of women between ages of 13–50 years (n = 2874*)

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Table 2: Obstetrical history of surveyed women

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School-going status, immunization status, and recurrent infection status of surveyed children below 12 years

Survey on 1483 children showed that 1481 (99.87%) had done immunization appropriate for age; 1320 (89.01%) had recurrent infections and 1234 (83.2%) were school-going [Table 3].
Table 3: School-going status, immunization status, and recurrent infection status of surveyed children below 12 years (n = 1483)

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Diseases most prevalent (5) among 4679 respondent (women) and their probable causes

  1. Sandhigatavata (polyarthritis): About 898 respondents were affected by this condition. Old-age-associated malnutrition, menopause, regular intake of dry food, over physical exertion, excess weight gain of body, excess consumption of tea/coffee, sleep disturbances, stress/anxiety, non-compliance to Ayurvedic daily regimen such as oil massage of body/proper exercise, etc., exposure to cold/cold water for drinking, non-compliance to Ayurvedic seasonal regimen especially in cold seasons, improper bathing of head in odd hours, suppression of natural urges of our body, and trauma could be the probable causes of polyarthritis in women.

  2. Vatavyadhi (musculoskeletal and neurological disorders): About 878 respondents were affected by this condition. All causes of polyarthritis as discussed and various factors depending on the particular disease could be the probable causes. For example, smoking, hypertension, and alcoholism which are the most common risk factors for neurological diseases such as CVA may be the causes.

  3. Rajonivrithijanya Rog (perimenopausal disorders): About 314 respondents were affected by this condition. Inadequate nutrition, variations in female sex hormone, and osteoporosis could be the probable causes.

  4. Gridrasi (sciatica): About 273 respondents were affected by this condition. All causes of polyarthritis as discussed, history of fall, lifting heavy weight from ground, and lumbar spondylosis/spondylitis/spondylolisthesis/IVDP could be the probable causes.

  5. Pandu (anemia): About 225 respondents were affected by this condition. Inadequate consumption of iron-rich food due to poverty, lack of awareness of iron-rich food, and poor digestion of food leading to improper assimilation of nutrients could be the probable causes [Figure 2].
Figure 2: Distribution of top 5 diseases predominant in the surveyed area among women

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Most prevalent diseases found in 208 respondents (children) along with their probable causes

  1. Agnimandya (indigestion of food/anorexia): 52 respondents were affected by this condition. Excess consumption of junk foods, worm infestations, constipation, and recurrent infections could be the probable reasons.

  2. Kasa (cough): 35 respondents were affected by this condition. Sudden climate changes (due to lack of proper seasonal regimen/regimen to be followed at the juncture of two seasons), sleeping directly under fan, allergic cough, exposure to dust and smoke could be the probable reasons. Infectious type of cough was seen especially in school-going children due to low immunity.

  3. Pandu (anemia): 17 respondents were affected by this condition. Mud eating, lack of awareness of iron-rich food among parents, poor digestion of food leading to improper assimilation of nutrients, and inadequate consumption of iron-rich food due to poverty could be the probable reasons.

  4. Kushta (skin diseases): 16 respondents were affected by this condition. Regular intake of food items such as fish + curd, papad+ curd, etc., fungal infections in people with poor hygiene, and allergy to various substances could be the probable reasons.

  5. Karshya (emaciation): 15 respondents were affected by this condition. Loss of appetite/indigestion, inadequate nutrition, worm infestations, poverty (though seen affected in a few family), and anemia could be the probable reasons [Figure 3].
Figure 3: Distribution of top 5 diseases predominant in the surveyed area among children

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  Discussion Top

The sociodemographic and other environmental related conditions have a highly influential role in determining the morbidity and mortality profile of the women and children in any country. As women bear gynecological, obstetrical problems apart from other health-related issues, their morbidity problems are basically complicated. A healthy reproductive life very much determines the general health and well-being of a woman.[6],[7] Improving child nutrition and health is a judicious long-term investment and moral imperative as healthy children grow into healthy adults; a healthy and productive population is an asset to any nation. Monitoring of their health serves as an extremely sensitive index in the general evaluation of health and nutrition standards of population.

Progressive public policies combined with distinctiveness in history led to population health indicators which are far superior to other states of India as far as Kerala state is concerned. Still, SC population of Kerala lags behind others in the health scenario.

Regarding the survey results of RCH team of RARILSD Thiruvananthapuram, as far as the status of the basic facilities of the houses in the villages is concerned, various types of housing schemes implemented by Government of Kerala such as One Lakh Housing Scheme, Suraksha Housing Scheme, New Suraksha Housing Scheme, etc. have definitely helped these people to live in houses with minimum standard facilities.[8]

Addictions were usually observed in people with comparatively low education level. Many people were using simple Ayurvedic home remedies in some diseases which they understood from parents or elderly, without consulting Ayurvedic doctors.

Regarding menstrual history and gynecological diseases, widespread advertisements on media and awareness activities by healthcare workers have helped the population to get information about sanitary napkins and contraceptives. Patients who approached for gynecological complaints were very less when compared with musculoskeletal complaints. Regarding obstetrical history of surveyed women, all indices point to the comparatively better reproductive health of the surveyed population.

Survey on children showed that only 12.2% had recurrent respiratory tract infections, 6.14% had recurrent gastrointestinal tract infections, and 3.57% had recurrent skin infections. About 89.01% had height expected according to age and 94.97% had weight expected according to age. As per a research conducted in 1999 on Child Health and Nutrition in Kerala, on the basis of weight for age, roughly 29% of children under the age of 4 were undernourished and 6% were severely undernourished, whereas according to height for age, 27% of the children were undernourished.[9]

As per the National Family Health Survey (NFHS-4), India, 2015–2016, weight loss was seen in 16% of the children and 7% of the children in Kerala were severely wasted. Also 3% of children were overweight and 16% were underweight, which implies both chronic and acute undernutrition.[10] These data clearly show that child nutritional status is progressing in due course of time in Kerala.

Most common disease conditions found among women were Sandhigatavata (polyarthritis), Vatavyadhi (musculoskeletal and neurological diseases), Rajonivrithijanyaroga (menopause-induced disorders), Gridrasi (sciatica), and Pandu (anemia). The highest prevalence of polyarthritis may be attributed to the old age changes such as osteoporosis after menopause and during perimenopausal period. Moreover, there is aggravation of vata humor in old age. Most common diseases among children were problems related to digestion of food/anorexia, cough, anemia, skin diseases, and emaciation.

Probably due to the high literacy and efficient healthcare delivery systems in Kerala, almost all pregnant women had all routine antenatal checkups and children were properly immunized for their age. Because of its achievements and progress in the field of health, Kerala state in India is often quoted as a model. With 99% institutional deliveries and 94% minimum three antenatal visits, health seeking behavior was reported to be high in this state for antenatal care services.[11]

Other major observations during the study related to antenatal and post-natal care were that all patients primarily chose allopathic management. Iron tablets and folic acid were taken correctly as per the requirement. Besides, most of the patients adopted traditional treatment methods for internal usage and external application for antenatal and post-natal care. Ayurvedic medicines (Dhanwantaram tablet) were taken mostly for the treatment of flatulence during pregnancy. Dhanwantaram Tailam was used for body massage before bathing and before and after pregnancy.

Good facilities for delivery are provided in all these panchayaths by modern government and private hospitals. Nutritional status was good among children and women. Though emaciation was the fifth predominant disease found, only 15 children were diagnosed of it among the surveyed population. Use of junk foods was found predominantly in children.

Another remarkable thing noted was the ignorance of public about the innumerable possibilities of Ayurveda medicine and system. A greater number of patients approached us for addressing their musculoskeletal problems, even though the main intention of the program was the improvement of reproductive health of women and child health. Ayurveda is generally considered as a treatment option for musculoskeletal disorders of the elderly people, even by comparatively more educated people. It is high time to break this public notion and to teach people to embrace Ayurvedic principles for utilizing a wide array of options in preventing and managing various spectrum of diseases.

As far as the practicing primary healthcare physicians and family physicians in our country are concerned, this study and its outcomes are very much relevant as they play a significant part in the early detection of diseases among women and children. They are the first level of contact of patients with the healthcare facilities. Moreover, without striving for proper institutional care, women suffer these morbidities silently. The reproductive health problems of women need greater attention. So it should be ensured that services for the early detection and treatment of gynecological problems are reaching properly for the needy.

  Conclusion Top

The facilities in health services provided by government such as hospitals for institutional deliveries, PHCs, etc. are adequate in selected areas. The disease conditions related to malnutrition were also not found in abundance. In the case of women, musculoskeletal diseases were found most prevalent than conditions affecting the reproductive system. For children, loss of appetite and respiratory diseases like cough were mostly seen. Probably being a state with one of the best literacy rates, only a very small percentage had poor socio-economic factors such as poor hygiene, addictions, using non-purified water for drinking, etc. But the people were not aware of the healthy lifestyle/food habits to be adopted. The study recommends to extend the project and to improve ease of access to antenatal care, Anganwadi services, and other healthcare facilities to those living in the far remote areas of Kerala by the concerned healthcare delivery institutions.

Clinical significance

Many patients were benefitted by the Ayurvedic treatment provided by our team and reported symptomatic and disease-wise relief. Awareness activities will definitely help to decrease the prevalence of many disease conditions such as anemia, worm infestations, etc. As it is a tedious job to carry out clinical examination on community settings on a large scale, community-based self-reports of morbidities have got great significance. To pilot sophisticated and advanced deliverance of healthcare services to women and children, the data collected through the present study can aid as a reliable primary data.

Financial support and sponsorship


Conflict of interest

There are no conflicts of interest.

  References Top

Guin NB, Nitin KP. Knowledge about RCH services among women in a selected rural area of Meerut. JNPE2018;4:27-30.  Back to cited text no. 1
Annual Report 2014–2015, Ministry of Health and Family Welfare. Chapter 4. Reproductive, Maternal, New born, Child and Adolescent Health Programme. Available from: https://main.mohfw.gov.in/sites/default/files/5665895455663325.pdf [Last accessed on 12 Jan, 2021].  Back to cited text no. 2
Panikar PGK, Soman CR. Health Status of Kerala: The Paradox of Economic Backwardness and Health Development. Trivandrum, Kerala: Centre for Development Studies; 1984.  Back to cited text no. 3
Bora JK, Raushan R, Lutz W. The persistent influence of caste on under-five mortality: Factors that explain the caste-based gap in high focus Indian states. PLoS ONE2019;14:e0211086.  Back to cited text no. 4
Census Data. Available from: https://censusindia.gov.in/2011-common/censusdata2011.html [Last accessed on 11 Jan, 2021].  Back to cited text no. 5
United Nations Population Information Network (POPIN). Guidelines on Reproductive Health. Available from: https://www.un.org/popin/unfpa/taskforce/ guide/iatfreph.gdl.html [Last accessed on 11 Jan, 2021].  Back to cited text no. 6
United Nations Population Fund. Sexual and Reproductive Health. Available from: https://www.unfpa.org/sexual-reproductive-health [Last accessed on 11 Jan, 2021].  Back to cited text no. 7
Housing-Govt. of Kerala, India. Official Web Portal Government of Kerala. Available from: https://kerala.gov.in/housing-department [Last accessed on 12 Jan, 2021].  Back to cited text no. 8
Navaneethan K, Thankappan KR. Reproductive and child health and nutrition in Kerala: Achievements and challenges. Regional Consultation on Priorities in Research in Reproductive and Child Health and Nutrition Jointly Organised by ICMR and UNICEF at Bangalore. 1999 October. Available from: https://www.researchgate.net/publication/282660821_Reproductive_and_Child_Health_and_Nutrition_in_Kerala_Achievements_and_Challenges [Last accessed on 12 Feb, 2021].  Back to cited text no. 9
National Family Health Survey (NFHS-4), INDIA, 2015–16, Kerala. Available from: http://rchiips.org/nfhs/NFHS-4Reports/Kerala.pdf [Last accessed on 12 Mar, 2021].  Back to cited text no. 10
Antenatal Care, Maternal Health. International Institute for Population Sciences and Macro International. National Family Health Survey, India, Kerala. Report number: 2005–06:3. Available from: http://rchiips.org/nfhs/NFHS-3%20Data/ke_state_report_for_website.pdf [Last accessed on 12 Feb, 2021].  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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