Abstract
Introduction
Salinity intrusion in coastal Bangladesh presents an escalating public health concern, disproportionately affecting women’s health. This study explores the association between salinity exposure and reproductive health problems among women of reproductive age, highlighting the need for targeted interventions and sustainable water management.
Study settings
The study was conducted in Gabura Union, Shyamnagar subdistrict of Satkhira district, a coastal area of Bangladesh highly vulnerable to saline intrusion. Data collection focused on assessing the impact of salinity, particularly reproductive health issues among women, while also evaluating access to fresh water, distance of health care facilities and practice to manage these challenges.
Methods
A cross-sectional study design was employed to assess the reproductive health impacts of salinity on women of reproductive age (18–49 years). A simple random sampling technique was employed to collect data from 234 household surveys.
Results
The findings revealed that water-dependent occupations (OR 3.916, 95% CI 1.944–7.888, p < 0.001), distance of safe drinking water (OR 12.621, 95% CI 4.150–38.385, p < 0.001), and distance of nearest health facility (OR 2.640, 95% CI 1.831–5.045, p = 0.003) were positively associated with an increased likelihood of reproductive health problems. These results highlight the significant role of environmental and resource constraints in exacerbating reproductive health challenges in salinity-affected regions.
Implications
The study identifies a strong association between salinity exposure and reproductive health issues, emphasizing the need for mobile health clinics specializing in reproductive health care, telemedicine services, subsidized household water filtration systems, and expanded rainwater harvesting projects in coastal areas. This study acknowledges certain limitations, including reliance on self-reported data, which may be subject to recall bias, and its cross-sectional design, which restricts causal interpretation. Future research should consider incorporating biomarker analysis, longitudinal designs, and appropriate comparison groups to strengthen causal inferences.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12905-025-03989-5.
Keywords: Salinity, Health impact, Reproductive health, Coastal, Bangladesh
Highlights
This study evaluated the impact of salinity on the reproductive health issues of coastal communities in Bangladesh.
This study explores the factors affecting the health and reproductive health of coastal communities.
This study examines the associations between the effects of reproductive health and occupation.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12905-025-03989-5.
Introduction
Water salinity refers to elevated levels of dissolved salts in water, particularly sodium and chloride ions [1]. It has emerged as a growing threat to freshwater resources, affecting both surface and groundwater in many coastal communities [2]. This environmental stressor compromises access to safe water, which is recognized as a fundamental human right and a core development priority [3]. Water salinity is a persistent environmental challenge across river deltas and coastal regions worldwide [4]. Major global deltas including the Nile (Egypt), Mississippi (USA), Burdekin (Australia), and Po (Italy) are experiencing increasing salinity threats [5]. In Asia, large transboundary mega deltas such as the Ganges Brahmaputra, Irrawaddy, Chao Phraya, Mekong, and Pearl River deltas face similar challenges, with the Ganga Brahmaputra Meghna (GBM) Delta experiencing significant impacts on health, livelihoods, and ecosystems [6]. Water salinity poses a serious barrier to sustainable development and affects several Sustainable Development Goals (SDGs), particularly those related to clean water, good health, and gender equality [7]. One critical pathway through which salinity affects human health is the disruption of safe water, sanitation, and hygiene (WASH) services, especially in low-resource, high-exposure settings[8].
Bangladesh is one of the most vulnerable countries affected by salinity intrusion [9]. Over 35 million people in its coastal region rely on drinking water sources with elevated salinity levels [10, 11].These populations are spread across 19 coastal districts, covering approximately 47,203 km2 and a 710 km coastline [12]. Only 12 percent of households in these regions have access to safely managed water services, while 64 percent lack even basic water access [12]. Many residents are forced to use water from saline contaminated ponds, rivers, or shallow tube wells, leading to a range of health risks [13]. In coastal areas of Bangladesh, water salinity exposure is widespread and occurs through multiple pathways. Seventy-one percent of people continue to use pond water for cooking, washing, and bathing, leading to frequent contact with saline water [14]. Additionally, exposure arises from drinking water sources [15], and livelihood activities such as fishing, farming, and aquaculture, which involve direct and prolonged contact with saline water and pose significant health risks [14, 16].
The lack of effective water governance, infrastructure, and sustainable resource management has further exacerbated disparities in access to safe water services [17]. These dynamics create a critical public health challenge, particularly for women in coastal regions who are disproportionately affected by a combination of social, economic, and environmental factors [16]. Rising water salinity, driven by climate change, significantly contributes to a range of health complications among women [18], while also amplifying their overall vulnerability in these high-risk areas [19, 20].
Although prior studies have documented associations between water salinity and conditions such as hypertension, diarrheal diseases, renal complications, and skin disorders [16, 18, 21, 22], but its impact on women’s reproductive health remains significantly understudied. Most research has focused narrowly on maternal health, particularly hypertensive disorders during pregnancy, neglecting broader reproductive outcomes such as menstrual irregularities, vaginal infections, urinary tract problems, and fertility issues. High salt intake during pregnancy has been linked to miscarriage and adverse birth outcomes [23]. Moreover, the use of saline water undermines menstrual hygiene, childbirth safety, and postnatal care, especially in contexts with poor access to safe water and healthcare [24].
The lack of gender sensitive, accessible reproductive health services in salinity affected areas exacerbates these risks [25], leaving many women untreated, misdiagnosed, or unaware of the threats. Social stigma and limited health literacy further prevent affected women from seeking timely care [26]. These reproductive health challenges are often excluded from public health programs and policy frameworks, reinforcing systemic neglect [27, 28].
Ensuring women’s reproductive health in coastal Bangladesh requires more than basic healthcare provision, it demands an understanding of how environmental stressors shape health outcomes. Women in salinity-affected areas face unique and often underreported challenges arising from daily interactions with unsafe water during cooking, bathing, sanitation, and livelihood activities. These cumulative exposures contribute to reproductive health problems that are not adequately recognized or addressed by current service delivery frameworks.
To address this critical research gap, this study investigates the association between water salinity exposure through water source types, collection patterns, and occupational contact and reproductive health outcomes among women of reproductive age in salinity affected areas of coastal Bangladesh. The findings aim to inform inclusive, context specific, and climate resilient reproductive health strategies that address environmental determinants and improve health equity for vulnerable coastal vulnerability.
Methodology
Study area
The study was conducted in Gabura union, which is located in Shymnagar, Satkhira, coastal Bangladesh (Fig. 1). This area was selected because of its high salinity levels, which have been reported to impact local populations health [29]. Gabura Union represents one of the most severely salinity-affected areas in Bangladesh, making it an ideal case study for understanding the health impacts of saline water intrusion. The region lies within the Ganges–Brahmaputra-Meghna (GBM) Delta, where increasing sea-level rise and upstream freshwater reduction exacerbate salinity intrusion [30]. However, Gabura faces periodic events of salinity intrusion, tidal surge, overtopping the embankments, poor embankment management, embankment breaching for bringing saline water for shrimp farming, and prolonged saline water logging [31].
Fig. 1.
Study area, Gabura Union, Satkhira, Bangladesh
Gabura in Shyamnagar Upazila, Satkhira District, experiences severe salinity intrusion, as indicated by high electrical conductivity (EC) of 20.2 dS/m and total dissolved solids (TDS) at 1.29%, far exceeding safe drinking Limits. The pH level of 8.4 reflects alkaline conditions, while sodium (3513.83 mg/L) and chloride (20,969.8 mg/L) concentrations are significantly above acceptable thresholds, affecting water quality and soil productivity. Bicarbonate levels (164.7 mg/L) further contribute to alkalinity [32].
Study design and sampling
A cross-sectional study design was employed to assess the reproductive health impacts of salinity among the women, aged between 18 to 49 years old. This study is part of a broader research initiative aimed at assessing the overall health impacts of salinity in coastal communities of Bangladesh. In the main study, the household was chosen as the sampling unit, and the total number of households was used as the finite population in Yamane’s formula. This approach ensured representativeness at the community level, capturing health impacts across all household members, including both male and female respondents. The estimated sample size was 382 households, with the objective of selecting one respondent per household based on predefined inclusion and exclusion criteria. The main study included individuals aged 18 to 80 years, prioritizing the household head as the primary respondent. If the household head was unavailable, the spouse was selected, and in the absence of both, the elder son or daughter was included. The study excluded children under 18 and individuals with cognitive disorders. The dataset included 120 males and 262 females, with 234 women aged 18–49 years participating in the gynaecological health component of the study. The reduced sample size in this component was a natural outcome of selecting only the female subset, rather than incomplete data collection.
To ensure representativeness, nine villages Lakshmikhali, Central Khalisha Bunia, Napitkhali, Parshemari, Gagramari, 9 No. Sora, 10 No. Sora, Chandnimukha, and Dumuria were randomly chosen from 15 villages to assess the health impacts of saline intrusion on residents. From these selected villages, a total of 382 households were proportionately allocated based on the household distribution in each village. A systematic random sampling technique was then implemented to ensure unbiased selection.
Household selection process
Determining the sampling interval
The total number of households in each village was recorded.
The sampling interval (k) was calculated using the formula:
 |
where:
N = Total number of households in the village.
n = Required sample size for that village.
This interval k was used to systematically select every kth household.
The first randomly selected household was used as the starting point for systematic sampling. The data enumerators started data collection from the starting point of each village encircling every kth peripheral household. After completing the peripheral households, two transverse directions from eastern part of the periphery to the western part crossing the centre and from northern part of the periphery to the southern part crossing the centre were covered.
Sample size determination
The sample size for the selected union was calculated via Yamane’s formula.
 |
where, n = the sample size.
N = Total number of households.
e = Level of precision (5 percent).
n = 8321/
1 + 8321(0.05)2, n = 381.69, = 382.
Data collection tool
To ensure the accuracy and reliability of self-reported reproductive health data, trained female enumerators conducted private interviews. A qualitative pilot study, including focus group discussions and key informant interviews with community health workers, midwives, and local women’s groups, was conducted to refine the survey language and cultural framing. Based on insights from the pilot study, a structured questionnaire was developed to ensure clarity and cultural sensitivity. Symptom-based questions were incorporated to encourage disclosure, while anonymity and confidentiality were ensured to minimize underreporting. The questionnaire was finalized with input from public health specialists, gynaecologists, and community health care providers (CHCPs) to strengthen its scientific rigor. The final questionnaire consisted of four sections: (i) demographic information, (ii) gynaecological health effects, (iii) safe drinking water and practices, and (iv) health facilities.
Informed consent process for sensitive questionnaire
The study involved the collection of sensitive health information, including self-reported reproductive symptoms and reproductive health issues. To ensure ethical compliance and participant comfort, a comprehensive informed consent process was implemented in line with international ethical guidelines (Declaration of Helsinki). The research adheres to strict ethical guidelines, with approval granted by Research Ethics Review Committee (RERC) of the Asian Institute of Technology (AIT) (Ref no RERC 2022/020. Informed consent was obtained from all participants prior to data collection. The consent process involved explaining the study objectives, procedures, and the voluntary nature of participation. Special attention was given to sensitive health-related questions, for which explicit verbal and written consent was obtained. Confidentiality was assured, and interviews were conducted in private to ensure participant comfort. This survey was conducted by female enumerators who received specialized training on ethical considerations and culturally sensitive interviewing techniques, ensuring appropriate handling of sensitive health topics.
Operational definition
Reproductive health
In this study, reproductive health problems are defined as a broad range of conditions affecting the female reproductive system that may be influenced by environmental stressors particularly salinity-induced freshwater scarcity, which impacts essential daily activities such as drinking, cooking, bathing, and sanitation. These environmental exposures can lead to poor hygiene, waterborne infections, and physiological stress, all of which may contribute to the development or worsening of reproductive health issues. Specifically, the study considered the following conditions for reproductive health problem: irregular menstruation, itching or burning in the genital area, leucorrhoea (white discharge), abnormal vaginal bleeding, pain during menstruation, miscarriage, discomfort or pain during sex, pelvic pain, early or delayed menarche, pain during urination, infertility or compromised fertility, inability to carry a pregnancy, pregnancy complications (e.g., fluid leakage from ruptured membranes, vaginal bleeding, gestational diabetes), as well as pre-eclampsia and eclampsia. These conditions were selected based on existing epidemiological and environmental health studies that have established links between salinity exposure and adverse reproductive health outcomes [16, 18, 24, 33]. To clarify the scope of health impacts in the context of salinity-related research gaps, these symptoms were descriptively grouped into two categories: maternal and pregnancy-related problems, and general gynaecological/reproductive issues. Women were asked if they had experienced any of these symptoms within the past 12 months. This recall period was considered appropriate in this study as it also included pregnant and lactating mothers, allowing sufficient time to capture relevant gynaecological and pregnancy-related symptoms that may arise before, during, or after pregnancy. This approach enabled the study to focus on reproductive health outcomes most plausibly linked to salinity exposure such as unsafe water use, inadequate hygiene, occupational exposure to saline environments, and limited access to healthcare services.
Practice toward safe drinking water
To assess practices related to safe water, five questions were used: water consumption habits, household water usage practices, adaptation measures for safe water practices, involvement in water safety activities, and water treatment and purification. A Likert scale questionnaire was employed to measure these practices, with each question rated on a scale from 1 to 5 (1 = never, 2 = rarely, 3 = seldom, 4 = often,5 = always). The total score for each respondent ranged from 5 to 25.
Occupation of the respondents
For the purpose of this study, respondents’ occupations were categorized based on the likelihood of exposure to saline water. Although detailed occupational data were collected (e.g., shrimp farming, fishing, rickshaw pulling, homemaking, trading etc.), these were recoded into two categories for analysis:
Water-dependent occupations (High Exposure): Occupations involving regular, direct, or prolonged contact with saline water, such as shrimp farming, fishing, pond-based activities, and day labour in water-logged or aquatic environments.
Water-independent occupations (Low Exposure): Occupations not involving direct exposure to saline water, such as homemakers, traders, government staff, students, and other dry-land based activities.
This dichotomous classification allowed for a clearer understanding of the relationship between occupational salinity exposure and reproductive health outcomes.
Education of the respondent
Respondents’ education levels were initially collected in multiple categories (e.g., illiterate, primary, secondary, higher secondary, graduate, madrasa). However, due to the small number of respondents with secondary or higher education, data were recoded into:
Illiterate: Respondents who reported no formal education.
Literate: Respondents with any level of formal education, including primary, secondary, higher secondary, or above.
Perceived health impact
Perceived reproductive health impacts in this study refer to how reproductive age group (18–49 years) individuals subjectively assess and interpret the effects of salinity on their reproductive and gynaecological health based on their own experiences, observations, and community knowledge. This approach allows for capturing localized perception regarding reproductive health problem impact due to water salinity that may not be fully reflected in clinical records, particularly in low-resource settings where access to healthcare is limited.
In low-income communities, accurately assessing perceived reproductive health impacts can be challenging due to limited health literacy and social stigma. Trained female enumerators clearly explained various reproductive health problems in simple, locally understood terms before asking respondents to assess their perceived impact, ensuring comprehension and reliability of responses. Structured ordinal scaling (1 = Very Low to 5 = Very High) was used to standardize responses and minimize reporting bias. Additionally, focus group discussions (FGDs), key informant interviews (KIIs), and local health records were used to validate self-reported data. These measures ensured that the study captured accurate and meaningful perceptions despite socio-economic constraints.
Surface water
Surface water includes pond, canal, or river water sources commonly accessed by the community [34].
Data analysis
The data were analysed with SPSS 26 version. The respondents were categorized into two groups: gynaecological problems absent and gynaecological problems present. Categorical data are presented as frequencies and percentages, while continuous data are expressed as means, standard deviations (± SDs).In the case of skewed data, the median with interquartile range (IQR) was used. The two groups were compared by Chi square test and Fisher exact test for categorical variables and the unpaired t test for the normally distributed continuous variables and Mann Whitney U test for skewed data. A p-value less than 0.05 was considered statistically significant in two tailed tests. All the parameters that obtained the level of significance were further investigated using a multivariate binary logistic analysis with a backward stepwise method.
Variable coding and interpretation for binary regression
To ensure clarity in odds ratio interpretation, all categorical variables were recoded such that the low-risk or protected category was used as the reference group (coded as 0), and the high-risk or exposed category was coded as 1. Specifically:
Occupational status: 0 = Homemaker (reference), 1 = Water-dependent.
Distance to safe drinking water: 0 = ≤ 1 km (reference), 1 = > 1 km.
Distance to nearest health facility: 0 = ≤ 2 km (reference), 1 = > 2 km and Continuous variables such as age and practice score were used in their original numeric form without recategorization or transformation.
The dependent variable, presence of reproductive health problems, was coded as 1 = Yes and 0 = No. This coding approach allows odds ratios > 1 to consistently indicate higher risk associated with the exposed group, improving interpretability of the logistic regression results.
Results
Sociodemographic characteristics and distribution reproductive health challenges among the respondents.
The study involved 234 women of reproductive age (18–49 years), with a mean age of 33.0 ± 6.8 years. Respondents’ occupational profiles revealed that a considerable portion (38.5%) were engaged in water-dependent work, such as shrimp farming and fish processing, while others were homemakers or involved in informal sectors. Household income was used as a proxy for economic status. The median monthly family income among participants reporting reproductive problems was slightly lower (8000 BDT [IQR: 6000–10,000]) than among those without such problems (9000 BDT [IQR: 7000–11,500]), although this difference was not statistically significant. These findings reflect a generally low-income population, consistent with the economic vulnerability of salinity-affected coastal communities. Educational attainment was also low, with 66.4% of respondents being illiterate. Housing conditions were mostly non-permanent (katcha or tin-shaded), and more than half of the participants used non-sanitary latrines. These indicators collectively point to a background of socioeconomic deprivation. The mean age of respondents with gynaecological problems (32.6 ± 7.6 years) is significantly lower than those without (34.8 ± 7.2 years) (p = 0.032). There is a highly significant association between occupation and the gynaecological problems (p < 0.001) (Table 1). Notably, younger age and water-dependent occupations were found to be significantly associated with the occurrence of reproductive problems among the respondents (Table 1).
Table 1.
Baseline characteristics of the respondents
| Baseline characteristics | Reproductive health problems | P value | |
|---|---|---|---|
| Absent | Present | ||
| Age, Mean ± SD | 34.8 ± 7.2 | 32.6 ± 7.6 | 0.032a |
| Occupational status | |||
| Home maker and water independent | 40.7% (57) | 59.3% (83) | < 0.001b |
| Water dependent | 17.0% (16) | 83.0% (78) | |
| Educational status | |||
| Illiterate | 33.6% (39) | 66.4% (77) | 0.427b |
| Literate | 28.8% (34) | 71.2% (84) | |
| Monthly family income, Median [IQR] | 9,000 [7,000, 11,5000] | 8000 [6000, 10,0000] | 0.143c |
| Housing material | |||
| Katcha | 31.7% (13) | 68.3% (28) | 0.714d |
| Tin shaded | 30.4% (55) | 69.6% (126) | |
| Semi Pacca | 41.7% (5) | 58.3% (7) | |
| Toilet condition | |||
| Non-sanitary | 33.3% (64) | 66.7% (128) | 0.131b |
| Sanitary | 21.4% (9) | 78.6% (33) | |
| Family member | 4.3 ± 1.4 | 4.6 ± 1.6 | 0.107a |
IQR interquartile range, SD standard deviation, aunpaired t test, bchi square test, cMann -Whitney U test, dFisher exact test
Among the 234 respondents, 161 (68.8%) females were suffered from different type of reproductive health problem (Table 1). The Table 2 highlights reproductive health challenges, with leucorrhoea (137 cases) and pain during menstruation (137 cases) being the most prevalent. Other common issues include irregular menstruation (100 cases), pelvic pain (83 cases), pain during urination (82 cases), and genital discomfort (72 cases), indicating a high burden of menstrual disorders and infections. Less frequent but significant concerns include abnormal vaginal bleeding (26 cases), miscarriage (20 cases), preeclampsia/eclampsia (18 cases), infertility (12 cases), and pregnancy complications (4 cases) (Table 2).
Table 2.
Distribution of respondents by reproductive health challenges(n = 234)
| Reproductive health challenges | Age mean ± SD | p value |
|---|---|---|
| Leucorrhoea (white discharge) (n = 137) | 32.1 ± 6.5 | < 0.001 |
| Pain during menstruation (n = 137) | 33.3 ± 7.3 | 0.181 |
| Irregular menstruation (n = 100) | 34.9 ± 5.7 | < 0.001 |
| Pain around the pelvis (n = 83) | 32.4 ± 6.5 | 0.037 |
| Painful micturition (n = 82) | 33.4 ± 6.9 | 0.627 |
| Itching or burning in the genital area (n = 72) | 33.5 ± 6.6 | 0.519 |
| Discomfort or pain during sex (n = 58) | 33.5 ± 6.1 | 0.575 |
| Abnormal vaginal bleeding (n = 26) | 33.7 ± 6.9 | 0.646 |
| Miscarriage (n = 20) | 29.2 ± 2.2 | < 0.001 |
| Pre-eclampsia or eclampsia (n = 18) | 33.4 ± 9.4 | 0.867 |
| Infertility or compromised fertility (n = 12) | 26.3 ± 2.5 | < 0.001 |
| Pregnancy complication (n = 4) | 23.0 ± 0.0 | < 0.001 |
SD standard deviation and p value was obtained while comparing the specific disease absent or present by Independent Sample t test
Association between perceived health impact and occurrence of reproductive health problems
The bar chart(Fig. 2) presents the relationship between perceived health impact (categorized as ‘Low’ or ‘High’) and the presence or absence of reproductive health problems among women in the study. Women without reproductive health problems were more likely to have a high risk perception, whereas affected women were more likely to have a low risk perception. This inverse relationship was statistically significant (p = 0.027).
Fig. 2.
Association between perceived health impact and occurrence of reproductive health problems. a Chi-square test
Association between reproductive health problems and water sources and practices of the respondents
In Table 3 shows there is a highly significant association between the access to safe fresh water and reproductive health problems (p < 0.001). A larger proportion of respondents traveling more than 1 km for safe drinking water have gynaecological problems (93.3%) compared to those within 1 km (60.3%). The mean practice score towards safe drinking water is significantly lower for respondents with reproductive health problems (9.7 ± 1.3) compared to those without (10.1 ± 1.3) (p = 0.017).
Table 3.
Water sources of the respondents (n = 234)
| Baseline characteristics | Reproductive health problems | P value | |
|---|---|---|---|
| Absent | Present | ||
| Drinking water | |||
| Tube well or filter | 10 (20.8%) | 38 (79.2%) | 0.200a |
| Rain water | 45 (36.6%) | 78 (63.4%) | |
| Open source | 20 (31.7%) | 43 (68.3%) | |
| Bathing water | |||
| Tube well or filter | 4 (19.0%) | 17 (81.0%) | 0.208a |
| Open source | 69 (32.4%) | 144 (67.6%) | |
| Toilet water | |||
| Tube well or filter | 5 (18.5%) | 22 (81.5%) | 0.131a |
| Open source | 68 (32.9%) | 139 (67.1%) | |
| Access to fresh water | |||
| Within 1 km | 69 (39.7%) | 105 (60.3%) | < 0.001a |
| > 1 km | 4 (6.7%) | 56 (93.3%) | |
| Practice towards safe drinking water, Mean ± SD | 10.1 ± 1.3 | 9.7 ± 1.3 | 0.017b |
SD standard deviation, aChi square test, bunpaired t test
Association of reproductive health problem and health facilities of the respondents
In Table 4 shows there is a significant association between the distance to the nearest health facility and reproductive health problems (p = 0.004). More respondents Living over 2 km from the nearest facility have reproductive health problems (76.7%) compared to those within 2 km (59.0%). The mean time to reach the nearest health facility is significantly longer for respondents with reproductive health problems (31.6 ± 13.1 min) compared to those without (27.2 ± 13.4 min) (p = 0.022).
Table 4.
Health facilities of the respondents (n = 234)
| Health facilities | Reproductive health problems | P value | |
|---|---|---|---|
| Absent | Present | ||
| Distance of nearest health facility | |||
| Within 2 km | 43 (41.0%) | 62 (59.0%) | 0.004a |
| > 2 km | 30 (23.3%) | 99 (76.7%) | |
| Time taken to reach nearest health facility, Mean ± SD | 27.2 ± 13.4 | 31.6 ± 13.1 | 0.022b |
SD standard deviation, aChi square test, bunpaired t test
Factors associated with reproductive health problems: a binary logistic regression model
A logistic regression was performed to ascertain the effects of socio-demographic, perceived health impact and health facilities of the respondents on occurrence of reproductive health problem. Occupational status (OR 3.916, 95% CI 1.944–7.888, p < 0.001), distance of safe drinking water (OR 12.621, 95% CI 4.150–38.385, p < 0.001), and distance of nearest health facility (OR 2.640, 95% CI 1.831–5.045, p = 0.003) were independent predictors of occurrence of reproductive problem (Table 5).
Table 5.
Binary logistic regression model of different independent variables in relation to occurrence of reproductive health problem (n = 234)
| Criteria | Odds ratio | 95% CI | p value |
|---|---|---|---|
| Age | 0.962 | 0.921–1.005 | 0.079 |
| Occupational status | |||
| Home maker and water independent | Ref | ||
| Water dependent | 3.916 | 1.944–7.888 | < 0.001 |
| Distance of safe drinking water | |||
| Within 1 km | Ref | ||
| > 1 km | 12.621 | 4.150–38.385 | < 0.001 |
| Distance of nearest health facility | |||
| Within 2 km | Ref | ||
| > 2 km | 2.640 | 1.831–5.045 | 0.003 |
| Practice | 0.801 | 0.629–1.019 | 0.070 |
Independent variables: age, occupational status, distance of safe drinking water, practice toward salinity, perceived health impact, distance of nearest health facility, time to reach nearest health facility from home, Backwardwald method, model at step 3
Exploratory distribution of specific reproductive health problems across key predictors
Following the identification of significant predictors from the multivariate regression model namely occupation, distance to safe drinking water, and distance to the nearest health facility this section presents an exploratory breakdown of how individual reproductive health problems vary across these key factors. Rather than testing associations, the analysis focuses on the visual distribution of specific symptoms (e.g., leucorrhoea, irregular menstruation, pelvic pain) using descriptive bar charts (Fig. 3). This approach helps illustrate how frequently each condition was reported among women with different occupational exposures (e.g., water-dependent vs. non-water-dependent jobs), varying access to safe water sources (> 1 km vs. ≤ 1 km), and differing proximity to healthcare facilities (> 2 km vs. ≤ 2 km). These visualizations offer insight into potential patterns of vulnerability and symptom clustering that can inform targeted public health interventions in salinity-affected areas.
Fig. 3.
Distribution of specific reproductive health problems by occupation, water access, and proximity of health facility
Discussion
This study aimed to investigate the relationship between salinity levels and health impacts in coastal communities. The analysis revealed that several independent variables were significantly associated with reproductive health problems. Specifically, age, water dependent occupation, access to fresh water, practices related to salinity, perceived health impacts, distance to the nearest health facility, and the time required to reach the nearest health facility from home were all significant predictors. These findings suggest that both individual and environmental factors play a critical role in the prevalence of reproductive health issues in the study population. An additional insight from the study highlights the relationship between risk perception and reported reproductive health problem symptoms. The study found that women who did not report reproductive health issues were more likely to have a high perception of health risks associated with water salinity. In contrast, women experiencing such problems exhibited comparatively lower perception. This paradox may suggest that greater awareness or perceived vulnerability functions as a protective factor, encouraging preventive practices such as avoiding prolonged contact with saline water, using safer water sources, or seeking timely medical care. Conversely, women with low perception may lack adequate knowledge, normalize discomfort due to cultural silence, or face barriers to openly discussing symptoms, which may result in underreporting and delayed care seeking. It is also plausible that women currently experiencing symptoms may not attribute them to water salinity due to limited health literacy. In some cases, previous personal or community experiences with reproductive illness may raise risk perception among asymptomatic women, even in the absence of current health problems. This finding highlights the sociobehavioral complexity of risk perception and reproductive health issues in salinity-exposed coastal areas.
A study conducted by Shamsuddoha et al. [16] found that women who had exposure to saline water by their occupation Linked to various reproductive health problems. Women who work in waist-deep water are particularly vulnerable to reproductive health problems. In coastal regions, most women are exposed to saline water through daily activities such as drinking, bathing, cooking. Additionally, Limited access to safe water often forces them to use unhygienic sanitation facilities, further increasing health risks. According to WHO Safe drinking water access means having a water source within a 1-km walking distance [35]. Our study found that about 93.3% respondent who had gynaecological problem have to fetch safe drinking water from more than 1 km which is significantly (P < 0.001) associated with reproductive health impact. Salinity leads to a shortage of fresh water, resulting in coastal residents needing to travel an average distance of approximately 2.4 km from their homes to access fresh water sources [14]. The distance to the primary water source was used in this study to reflect water access, but its link to reproductive health should be interpreted carefully.Distance traveled to collect water does not necessarily reflect actual exposure to water salinity. Proximity doesn’t guarantee safety, and some women close to safe drinking water sources may have higher health risks. Conversely, women traveling longer distances may still be healthier, possibly due to better coping capacity or other unmeasured factors.
Elevated salinity in coastal areas, through activities like drinking, cooking, and bathing, has been associated with an increased risk of different types of diseases (Asma & Kotani 2021). On the other hand, scarcity of fresh water put a strain on WASH (Water, sanitation and Hygiene). Our study also highlighted the impact of safe water practices on reproductive health. Lack of basic sanitation is strongly linked to higher chances of miscarriage and increased risk of high fever during labour, indicating infection [36]. This study also found that age distribution among women with reproductive health challenges, highlighting significant associations for some conditions. Leucorrhoea, irregular menstruation, miscarriage, infertility, and pregnancy complications are more common in younger women (p < 0.001), while pelvic pain (p = 0.037) also shows a mild age-related association. Other conditions, such as pain during menstruation, urination, and pre-eclampsia, show no significant age differences (p > 0.05) (Table 2). A study revealed that the majority of women and girls living in coastal areas reported that salinity negatively impacts their menstrual health and hygiene, leading to issues such as rashes, fungal infections, itching in sensitive areas and urinary tract infections [18]. Another study found that residents of coastal Bangladesh faced several health problems linked to salinity, such as menstrual hygiene issues, miscarriages, pregnancy-related hypertension, pre-eclampsia/eclampsia, urinary tract infections (UTI), and some had hysterectomies due to prolonged bleeding, infections, or tumours [16]. These associations between salinity exposure and reproductive health outcomes may be underpinned by plausible biological mechanisms. Chronic ingestion or dermal contact with saline-contaminated water can lead to dehydration and mucosal irritation, disrupting the vaginal microbiota and increasing susceptibility to infections [37]. Additionally, exposure to heavy metals and other contaminants commonly found in saline water may induce systemic inflammation or oxidative stress, potentially affecting reproductive tissues [38]. Endocrine-disrupting compounds in contaminated water may further alter hormonal regulation, contributing to menstrual irregularities, infertility, or pregnancy complications [39]. While these mechanisms remain hypothetical within the scope of this study, they highlight the importance of interdisciplinary research integrating environmental, biomedical, and clinical perspectives.
However, health care facilities in remote coastal areas of Bangladesh are often less comprehensive, farther away, and more expensive to reach than urban hospitals, worsening the situation for the poor living there [40]. Our study also highlighted the reproductive health impact also significantly associated with the distance of healthcare facilities(P < 0.003). In the study area distance of health care facility is a factor due to road infrastructure and lack of transportation. Most of the roads are unpaved and difficult to reach health care centre especially rainy season. In the coastal area, marginalized population depends on community clinic which is not sufficient for providing all kinds of reproductive health treatment. According to the guidelines for community clinics, no qualified doctor is assigned to these facilities. Each clinic is managed by a Community Healthcare Provider (CHCP), who works six days a week. Additionally, a Health Assistant (HA) and a Family Welfare Assistant (FWA) alternate their duties, each working three days a week [41]. It is essential to establish health facilities in coastal regions of Bangladesh based on the specific needs and demands of the local population. However, proximity alone does not guarantee effective healthcare access. In our study, distance to health facilities was used as a proxy for physical accessibility. The quality and functionality of these facilities including availability of qualified personnel, essential medicines, and specialized reproductive health services are critical determinants of service utilization and health outcomes. A nearby facility without adequate staffing or supplies may not meet community needs, potentially leading to delayed or forgone care.
On the other hand, while the association between water practices and reproductive health may not have shown strong statistical significance, However, local adaptations and water use practices provide valuable insights into community resilience and health behavior. These practices reflect cultural, economic, and infrastructural constraints faced by women in coastal regions. The key water practices identified are Rainwater Harvesting, Pond Sand Filters (PSFs) and ponds. Interestingly, a higher prevalence of reproductive health problems was also reported among women who relied on rainwater for drinking.Although rainwater is often considered the safest drinking water option in coastal regions, it does not fully eliminate salinity-related exposure risks.This finding may reflect several contextual factors. While rainwater is typically considered a safer option compared to pond or tube well water, the high proportion of reproductive health issues among rainwater users in our study may reflect several contextual factors: Despite drinking rainwater, continued use of saline water for daily tasks may result in cumulative exposure, contributing to reproductive health issues. Limited availability of stored rainwater throughout the year may force women to alternate between multiple unsafe sources, including pond or canal water, especially during dry seasons. Storage and handling practices for rainwater may introduce contamination, particularly where appropriate infrastructure (e.g., sealed tanks, covered containers) is lacking.Women reporting use of rainwater may also represent those already experiencing health issues who have switched to rainwater as a coping strategy, leading to a reverse causation effect. Additionally, in coastal Bangladesh, no single water source is consistently reliable or risk-free, and communities often use a mix of water types for drinking, bathing, and household tasks. Conversely, the observed association between rainwater consumption and reproductive health outcomes merits further empirical investigation to clarify potential underlying mechanisms or confounding factors. Many households collect and store rainwater during the monsoon season for drinking and cooking [42] However, this seasonal reliance is often inadequate for year-round use, highlighting the need for more sustainable and reliable water sources [43]. Community ponds equipped with Pond Sand Filters are another important water source, used for drinking and cooking. Unfortunately, these Pond Sand Filters often degrade over time or become unusable during dry seasons, limiting their effectiveness [44]. Some families even travel to neighboring unions to access less saline water for household use, adding to the time burden on women [45]. Despite these efforts to harvest rainwater or filter pond water, the overwhelming reliance on saline water for daily needs contributes to consistent exposure, potentially limiting the protective effect of these practices [46].The challenges faced by women in coastal regions reflect broader issues of water governance and infrastructure. Improving water access and challenging gender stereotypes are crucial steps in addressing the disproportionate burden placed on women [47] Furthermore, the sociocultural determinants of water, sanitation, and hygiene practices identified highlight the need for a holistic, community-based approach to improving water security and public health outcomes [48].
While the study population resides in salinity-affected coastal communities and shares common environmental exposure, variability in reproductive health outcomes can be explained by differential exposure levels. Women in water-dependent occupations (e.g., shrimp farming, fishing) experience higher exposure levels, increasing their risk of reproductive health issues. Women who primarily stay at home have less prolonged exposure to saline water and, as a result, report fewer reproductive symptoms compared to those who regularly rely on saline sources for daily activities. On the other hand, coping capacity and behavioral differences effects on reproductive health problem sysmptoms. Household coping strategies (e.g., water filtration, hygiene practices) and health-seeking behaviors vary across the population, contributing to differences in reported symptoms. Health resilience also plays a role, with some individuals exhibiting stronger immune responses to environmental stressors. Our study identifies an association between salinity (environmental exposure, individual exposure levels, coping capacity, and occupational risks) and its impact on reproductive health but not causality. Multivariate analysis controlled for confounding factors, reinforcing the conclusion that salinity is a contributing factor to reproductive health problems in coastal communities.
Policy implementation and recommendation
Addressing this silent threat requires a multifaceted approach. To strengthen the policy relevance of our findings, we propose a set of actionable health system interventions tailored to the reproductive health needs of women in saline-affected coastal areas.Specific intervention such as (1) implementing mobile reproductive/gynaecological health clinics in remote saline-prone areas to improve service outreach; (2) integrating telemedicine platforms into existing community clinics to connect patients with specialist care; (3) designing gender-sensitive WASH (Water, Sanitation, and Hygiene) programs that address the unique needs of women exposed to saline water sources; and (4) strengthening the capacity of community health workers (CHWs) through training in reproductive health screening, awareness,counselling, and referral pathways. These measures aim to bridge healthcare access gaps and promote place-based climate-resilient health systems for the unmet needs of vulnerable coastal populations
Limitation of the study
This study has several limitations that should be acknowledged. As a cross-sectional study, it captures associations at a single point in time, limiting the ability to establish causal relationships between salinity exposure and reproductive health outcomes. The study was conducted within a single union without a comparison group due to resources and time limitation, restricting the generalizability of the findings to broader salinity-affected populations. Additionally, the reliance on self-reported data introduces the potential for recall bias. While salinity exposure is central to this study, it was assessed indirectly using proxy variables such as primary water source, distance to safe drinking water, and occupation type. These indicators were chosen for feasibility and relevance to local context. However, we acknowledge this approach limits exposure quantification precision. Future research should incorporate direct environmental salinity measurements (e.g., sodium levels, electrical conductivity) and biological markers (e.g., urinary or serum sodium) to improve the exposure response validity and strengthen causal inference and comparison group with multisite studies are also encouraged. A deeper understanding of actual water quality and how water is used in daily life is needed in future research.
Conclusion
The gynaecological health challenges in coastal Bangladesh represent a pressing and often overlooked issue exacerbated by the increasing salinity of water sources. This silent threat significantly impacts different types of women’s reproductive health issues associated with age, occupation, distance of fresh water source and health facilities and practice towards the safe water. Unlike most studies focusing on maternal health, this research highlights broader gynaecological conditions, including non-maternal and maternal gynaecological problems. Appropriate statistical methods, including multivariate regression analysis, were employed to adjust for potential confounding factors, enhancing the reliability of the findings. These insights contribute valuable new evidence to an under-researched area and this study provides foundational evidence linking water salinity exposure to reproductive health challenges among women in coastal Bangladesh. While the findings highlight urgent areas for public health and environmental intervention, they also underscore the need for further longitudinal research and biomedical investigation to establish causal pathways and clarify underlying biological mechanisms. Expanding this evidence base is essential for designing targeted, context-specific reproductive health services and water safety strategies. Such efforts will support the realization of Sustainable Development Goal (SDG) 3 (Good Health and Well-being) and SDG 6 (Clean Water and Sanitation). Ultimately, this research lays the groundwork for more comprehensive studies that can inform robust, evidence-based policymaking in climate-vulnerable regions.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We would also like to acknowledge the support received from the library of the Asian Institute of Technology and Nowabeki Gonomukhi Foundation (NGF), Satkhira, Bangladesh.
Md. Mahfuz Hossain
Mr. Md. Mahfuz Hossain is an Assistant Professor at Jahangirnagar University, Bangladesh, currently pursuing a PhD in Disaster Preparedness Mitigation and Management in AIT, Thailand. Research focuses on disaster management, public health, and infectious and noncommunicable diseases and published extensively in reputable journals. He holds an MPH and DDS and from Bangabandhu Sheikh Mujib Medical University and BDS from Dhaka Dental College in Bangladesh. And Dr. Indrajit Pal is an Associate Professor and Chair of Disaster Preparedness, Mitigation and Management Program at AIT, Thailand. He has authored 14 books and over 100 articles, focusing on resilience, risk reduction, and public health in disasters. Dr. Pal holds a Ph.D. in Seismotectonic and Earthquake Hazard Assessment and has extensive experience in both academic and advisory roles.
Author contributions
Author contribution Conceptualization: IP, MH; Methodology: Draft preparation: Writing—review and editing: MH, IP; Data collection and analysis: MH.
Funding
This research and manuscript were not supported by any Grant.
Data availability
The datasets used and/or analyzed during the current study are not publicly available due to institutional restrictions and participant confidentiality but are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Research Ethics Review Committee (RERC) of the Asian Institute of Technology (AIT) (Ref. No. RERC 2022/020). All participants were informed about the study objectives, procedures, and potential benefits, and provided written informed consent prior to participation. Data confidentiality and participant privacy were maintained throughout the research process.
Consent for publication
Not applicable. This manuscript does not contain any individual person’s identifiable data in any form (including images, videos, or clinical details).
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Li C, Gao X, Li S, Bundschuh J. A review of the distribution, sources, genesis, and environmental concerns of salinity in groundwater. Environ Sci Pollut Res. 2020;27(33):41157–74. [DOI] [PubMed] [Google Scholar]
- 2.Rakib MA, Sasaki J, Matsuda H, Quraishi SB, Mahmud MdJ, Bodrud-Doza Md, et al. Groundwater salinization and associated co-contamination risk increase severe drinking water vulnerabilities in the southwestern coast of Bangladesh. Chemosphere. 2020;246: 125646. [DOI] [PubMed] [Google Scholar]
- 3.Bain R, Johnston R, Slaymaker T. Drinking water quality and the SDGs. NPJ Clean Water. 2020;3(1):7–9. [Google Scholar]
- 4.Rahman MM, Penny G, Mondal MS, Zaman MH, Kryston A, Salehin M, et al. Salinization in large river deltas: drivers, impacts and socio-hydrological feedbacks. Water Secur. 2018;2019(6): 100024. [Google Scholar]
- 5.van Engelen J, Oude Essink GHP, Bierkens MFP. Sustainability of fresh groundwater resources in fifteen major deltas around the world. Environ Res Lett. 2022;17(12).
- 6.Akter R, Asik TZ, Sakib M, Akter M, Sakib MN, Al Azad ASMA, et al. The dominant climate change event for salinity intrusion in the GBM delta. Climate. 2019;7(5):1–23. [Google Scholar]
- 7.Singh A. Soil salinity : a global threat to sustainable development. 2021;0–29.
- 8.Hossain MdM, Pal I, Ahmad MM, Loc HH. Conceptualizing saline exposure model (SEM) for health impacts in the delta community in Bangladesh: a systematic literature review and field observations. Environ Claims J. 2025;0(0):1–30.
- 9.Roy T, Chandra D, Sony MMAAM, Rahman MdS. Impact of salinity intrusion on health of coastal people: reflections from dacope upazila of khulna district, Bangladesh. Khulna University Studies. 2022;57–66.
- 10.Vineis P, Chan Q, Khan A. Climate change impacts on water salinity and health. J Epidemiol Glob Health. 2011;1(1):5–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Talukder MRR, Rutherford S, Phung D, Islam MZ, Chu C. The effect of drinking water salinity on blood pressure in young adults of coastal Bangladesh. Environ Pollut. 2016;214(Jul 1):248–54. [DOI] [PubMed] [Google Scholar]
- 12.Shampa MTA, Shimu NJ, Chowdhury KMA, Islam MM, Ahmed MK. A comprehensive review on sustainable coastal zone management in Bangladesh: present status and the way forward. Heliyon. 2023;9(8): e18190. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Naus FL, Burer K, van Laerhoven F, Griffioen J, Ahmed KM, Schot P. Why do people remain attached to unsafe drinking water options? Quantitative evidence from southwestern Bangladesh. Water. 2020. 10.3390/w12020342. [Google Scholar]
- 14.Haque M, Haque MA, Haque A, Ansari MS. Water, sanitation and health status of aila affected coastal area of Bangladesh. Bangladesh J Environ Sci. 2010;2010(19):51–6. [Google Scholar]
- 15.Chakraborty R, Khan KM, Dibaba DT, Khan MA, Ahmed A, Islam MZ. Health implications of drinking water salinity in coastal areas of Bangladesh. Int J Environ Res Public Health. 2019;16(19):1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Shamsuddoha M, Jabed MA, Islam MS, Sultana N, Imran A, Rabbi SNA, et al. Impacts of climate change-induced natural hazards on women and their human rights implications: a study in the southwest coast of Bangladesh. J Migr Health. 2024;9:100221. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Lam Y, Winch PJ, Nizame FA, Broaddus-Shea ET, Harun MGD, Surkan PJ. Salinity and food security in southwest coastal Bangladesh: impacts on household food production and strategies for adaptation. Food Secur. 2022;14(1):229–48. [Google Scholar]
- 18.Khanam D, Kabir Z, Dina SA, Islam AR. Experiencing the impacts of climate change-induced salinity by women in coastal region of Bangladesh. J Climate Action, Res, Policy. 2023;01:1–33. [Google Scholar]
- 19.Roy T, Chandra D, Sony MMAAM, Rahman MdS. Impact of salinity intrusion on health of coastal people: reflections from dacope upazila of khulna district, Bangladesh. Khulna University Stud. 2022;57–66.
- 20.Ahmad MM, Saqib SE. Salinity and the health of the poor in coastal Bangladesh. Disaster resilience and sustainability: adaptation for sustainable development. Elsevier; 2021; pp. 563–575.
- 21.Md A, Gomes C, Dias JM, Cerdà A. Exploring gender and climate change nexus, and empowering women in the south western coastal region of Bangladesh for adaptation and mitigation. Climate. 2022;10(11).
- 22.Ahmed S, Eklund E. Climate change impacts in coastal Bangladesh: migration, gender and environmental injustice. Asian Aff. 2021;52(1):155–74. [Google Scholar]
- 23.Abdoli A. Salt and miscarriage: Is there a link? Med Hypotheses. 2016;89:58–62. [DOI] [PubMed] [Google Scholar]
- 24.Sinha S, Ahmad R, Chowdhury K, Ferdaus F, Banik S, Mehta M, et al. The impact of saline water on women’s health in the coastal region of Bangladesh: special attention on menstrual hygiene practices. Cureus. 2024;16(8):1–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Husaini S, Davies SE. Case report: another burden to bear: the impacts of climate change on access to sexual and reproductive health rights and services in Bangladesh. Front Climate. 2022;4(June).
- 26.Lee SYD, Arozullah AM, Cho YI. Health literacy, social support, and health: a research agenda. Soc Sci Med. 2004;58(7):1309–21. [DOI] [PubMed] [Google Scholar]
- 27.Sen G, Östlin P, George A. Unequal , Unfair , Ineffective and Inefficient Gender Inequity in Health : Why it exists and how we can change it Final Report to the WHO Commission on Social Determinants of Health Women and Gender Equity Knowledge Network Gita Sen and Piroska Östlin Rev. World Health. 2007;1–145.
- 28.Hart J, Crear-Perry J, Stern L. US sexual and reproductive health policy: which frameworks are needed now, and next steps forward. Am J Public Health. 2022;112:S518–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Abedin MA, Habiba U, Shaw R. Community perception and adaptation to safe drinking water scarcity: salinity, arsenic, and drought risks in coastal Bangladesh. Int J Disaster Risk Sci. 2014;5(2):110–24. [Google Scholar]
- 30.Rakib MA, Sasaki J, Matsuda H, Fukunaga M. Severe salinity contamination in drinking water and associated human health hazards increase migration risk in the southwestern coastal part of Bangladesh. J Environ Manage. 2019;240(April):238–48. [DOI] [PubMed] [Google Scholar]
- 31.Rahman MM, Penny G, Mondal MS, Zaman MH, Kryston A, Salehin M, et al. Salinization in large river deltas: drivers, impacts and socio-hydrological feedbacks. Water Secur. 2019;6: 100024. [Google Scholar]
- 32.Ashrafuzzaman M, Artemi C, Santos FD, Schmidt L. Current and future salinity intrusion in the south-western coastal region of Bangladesh. Spanish J Soil Sci. 2022;12.
- 33.Khan AE, Scheelbeek PFD, Shilpi AB, Chan Q, Mojumder SK, Rahman A, et al. Salinity in drinking water and the risk of (pre)eclampsia and gestational hypertension in coastal Bangladesh: a case-control study. PLoS ONE. 2014;9(9):e108715–e108715. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Bwire G, Sack DA, Kagirita A, Obala T, Debes AK, Ram M, et al. The quality of drinking and domestic water from the surface water sources (lakes, rivers, irrigation canals and ponds) and springs in cholera prone communities of Uganda: an analysis of vital physicochemical parameters. BMC Public Health. 2020;20(1):1–18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Nygren BL, O’Reilly CE, Rajasingham A, Omore R, Ombok M, Awuor AO, et al. The relationship between distance to water source and moderate-to-severe diarrhea in the global enterics multi-center study in Kenya, 2008–2011. Am J Trop Med Hyg. 2016;94(5):1143–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Cameron L, Chase C, Contreras SD. Relationship between water and sanitation and maternal health: Evidence from Indonesia. World Dev. 2021;147: 105637. [Google Scholar]
- 37.Chen Y, Bruning E, Rubino J, Eder SE. Role of female intimate hygiene in vulvovaginal health: global hygiene practices and product usage. Womens Health. 2017;13(3):58–67. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Lauriola P, Ruadze E, Singh K, Xu J, Lin J, Lin X, et al. International Society Doctors for the Environment (ISDE), Italy REVIEWED BY Association between heavy metals exposure and infertility among American women aged dd-years: A cross-sectional analysis from mmmm to oooo NHANES data. 2023;
- 39.Gonsioroski A, Mourikes VE, Flaws JA. Endocrine disruptors in water and their effects on the reproductive system. Int J Mol Sci. 2020. 10.3390/ijms21061929. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Iqbal MH. Disparities of health service for the poor in the coastal area: does Universal health coverage reduce disparities? J Mark Access Health Policy. 2019;7(1):1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Riaz BK, Ali L, Ahmad SA, Islam MZ, Ahmed KR, Hossain S. Community clinics in Bangladesh: a unique example of public-private partnership. Heliyon. 2020;6(5): e03950. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Nijhof S, Jantowski B, Meerman R, Schoemaker ARD. Rainwater harvesting in challenging environments: towards institutional frameworks for sustainable domestic water supply. Waterlines. 2010;29(3):209–19. [Google Scholar]
- 43.Ahmed F, Kadir A, Kamal I, Hossain M. A review of current water governance in Bangladesh: a case study on administrative and performance of water policy. Sci Res J (SCIRJ). 2023;XI(Xii):1–11. [Google Scholar]
- 44.Alam FMA, Islam MS, Ghosh GC, Yeasmin T. Assessing the drinking water quality and performance of pond sand filters (PSF) in coastal area of Bangladesh: a cross sectional study on dacop upazila of Khulna. Int J Adv Geosci. 2017;5(2):69. [Google Scholar]
- 45.Jaren LS, Leya RS, Mondal MS. Investigation of gender-differentiated impacts of water poverty on different livelihood groups in peri-urban areas around Dhaka, Bangladesh. Water. 2022. 10.3390/w14071167. [Google Scholar]
- 46.Sonchieu J, Tapaat C. Water safety: management, perception and health implications in Santa agricultural area, North-West Region, Cameroon. Hydrol Sci J. 2020;65(11):1848–55. [Google Scholar]
- 47.Chan NW, Roy R, Chaffin BC. Water governance in Bangladesh: an evaluation of institutional and political context. Water (Switzerland). 2016;8(9):1–18. [Google Scholar]
- 48.Okesanya OJ, Eshun G, Ukoaka BM, Manirambona E, Olabode ON, Adesola RO, et al. Water, sanitation, and hygiene (WASH) practices in Africa: exploring the effects on public health and sustainable development plans. Trop Med Health. 2024. 10.1186/s41182-024-00614-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are not publicly available due to institutional restrictions and participant confidentiality but are available from the corresponding author on reasonable request.