This story was co-published with The Fuller Project

The pandemic is always on the back of Riya Gupta’s mind. As a pregnant commuter in Delhi, one of the world’s most densely populated cities, she worries about reports that Covid-19 can result in complications and affect her baby’s development. But while the sense of urgency around the pandemic recedes, another source of concern looms larger: air pollution.

If Covid-19 is a “direct killer”, Gupta, who works in public health communications, calls air pollution “the slow killer”.

“I’ve been coming across research recently on how [air] pollution, specifically in Delhi, would have direct consequences for my child, both in terms of weight and increasing the risk of prematurity,” said Gupta. “Given that I’m in my second trimester right now, all of this does scare me a lot.”

A global problem

Gupta’s hometown Delhi is the world’s most polluted capital, according to data from IQAir, a Swiss company that collects real-time air quality information. The problem is a truly global one – as much as 99% of the world’s population breathes in air with pollution levels higher than World Health Organisation’s safe limits. But the highest levels are found in poor and developing countries, where most of the seven million annual deaths linked to air pollution are concentrated.

Public health officials have mostly focused so far on respiratory diseases and the impact on young children. With relatively little research available on the impact of air pollution on women’s reproductive health, or the different ways in which men and women are exposed, the issue has mostly slipped under their radar.

“Exposure to air pollution during pregnancy is associated with complications or adverse events during pregnancy [e.g., preeclampsia, miscarriage, gestational diabetes, high blood pressure] and adverse birth outcomes such as pre-term birth, low birth weight or in some cases, stillbirth,” said Pallavi Pant, a senior scientist at the Boston-based Health Effects Institute. “Some studies have also linked air pollution with lower fertility rates or depression among pregnant women.”

It is not just outdoor air pollution - women in the densely-populated region are also disproportionately hit by high levels of poor-quality air indoors as they tend to be primarily responsible for cooking, and firewood continues to be widely used as a source of cooking fuel, emerging studies show. In India alone, an estimate finds that 0.61 million deaths were attributable to indoor air pollution, though the data was not segregated by gender.

“Lack of access to clean energy also means that women are often responsible for collection of fuelwood, and this takes time away from other productive or recreational tasks,” said Pant, a key contributor to the State of the Global Air report, which provides annual analysis of global trends in air quality and its impact on health. And as indoor air pollution also affects young children, women are saddled with the dual burden of caring for their own health as well as that of a sick child.

Much of this evidence has only emerged in recent years, as availability of data has improved.

Climate gains of improving air quality

Pollution levels are significantly higher in much of the developing world. It is worst in South Asia, where in 2021, 18 of the world’s 20 most polluted cities were spread across the Indo-Gangetic plain in India and Pakistan. Four of the 10 worst countries for air pollution according to IQAir are in South Asia: Bangladesh, Pakistan, India and Nepal.

Here, most people breathe air with pollution levels several dozen times higher than the WHO safe limits, according to the State of the Global Air report 2020 released this March. And not much appears to be changing. The report found that air quality in India and Nepal in particular had shown very little improvement over the past decade. Existing research estimates the current air pollution could shave off up to a decade from the life expectancy of people in the region. And some modeling studies suggest improving air quality in South Asia alone would prevent 7% pregnancy losses in the region.

Many of the particulate pollutants that cause air pollution also contribute to the greenhouse effect and global temperature rise, according to the WHO, whose director for public health and environment Dr Maria Neira has, for the past few years, been making the case that the solutions to cleaning up our air will also have clear climate gains.

Benefits to women go beyond better air quality

Solutions to improve air quality would also have other benefits. Expanded access to clean cooking fuels reduces the need for time-consuming wood and biogas fuel gathering, usually done by women and girls, thus leading to gains in health and gender equality, said Pant.

More broadly, investments in cleaner household cooking and lighting solutions, including more renewables such as solar electrification and biogas fuel, go hand in hand with expanding energy access, a key United Nations Sustainable Development Goal.

In the meantime, policy makers need to factor in gender differences in exposure levels, said Azra Khan, a programme manager with the cities and transport team at the think tank WRI-India.

Along with breathing in more polluted air in the home, women are in fact more likely to be exposed to air pollution outdoors, she said. One pilot study in India’s Bhopal city found women were more likely to walk to work and hence breathe in higher levels of outdoor air pollution during their daily journeys to and from home.

Women engaged in low-paying jobs such as street sweeping, construction and street vending also face high levels of exposure, said Khan, observing that most data on gender inequalities in air pollution exposures are mainly focused on household air pollution. “But what beyond that, and how is it [air pollution] contributing to their overall health outside of their caregiving responsibilities?” Khan asked. “That data is not there.”

Authorities don’t factor gender into solutions

Authorities do not currently factor gender in their solutions. Tanushree Ganguly, an air quality researcher at the Council of Energy, Environment and Water, and her collaborators examined 102 air cleaning plans for Indian cities. She pointed out that though India’s National Clean Air Programme refers to the impact of indoor pollution on women and children, the city-level plans do not explicitly look at gender.

“[If] I’m undertaking actions which are aimed at reducing air pollution, they all impact the residents of the city, which of course includes women and children,” Ganguly observed.

One of the few initiatives that targets women is a flagship government program on household air pollution. Called Pradhan Mantri Ujjwala Yojana, it aims to enable rural and poor households to transition to cleaner cooking fuels by providing them with cooking gas cylinders, but has met with limited success and gaps remain.

In terms of ambient air pollution issues, localised strategies such as the erection of smog towers in Delhi also have failed to make an impact. Large scale initiatives supporting transitioning to renewable energy is promising but so far hasn’t helped significantly reduce air pollution as the country still heavily relies on coal fuelled thermal power plants.

While people can limit their exposure to air pollution by using air purifiers when indoors, there is not much they can do when outdoors, said Ganguly. Cities will have to find ways to promote clean transportation, improve waste management and reduce dust.

Gupta, who grew up in Delhi, is resigned to breathing in polluted air, saying that even after installing indoor air purifiers there is only so much control she has over her immediate environment. “I have to travel to work. No matter what I do, I am exposed,” she said.