Opportunities for Improvement: Lessons from the WASH & CLEAN Study in India and Bangladesh

Session: Water, Sanitation and Hygiene (WASH) and Maternal and Newborn Health – Using What We Know to Accelerate Progress on WASH Access and Maternal and Newborn Health Outcomes

Presenter: Kranti Vora, Indian Institute of Public Health Gandhinagar, Gujarat, India
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Background: There is growing recognition of the importance of water, sanitation and hygiene (WASH) and infection prevention and control (IPC) in healthcare institutions for maternal and newborn health. Research dedicated to exploring these relationships and informing improvements, however, remains comparatively limited. The WASH & CLEAN collaborative study developed new tools to assess WASH and IPC on maternity units and was conducted in Gujarat State, India, and Dhaka Division, Bangladesh in 2013-14.

Methodology:  A mixed methods approach was adopted. In each maternity unit, a walk-through of the antenatal and postnatal wards and the labour room was undertaken. Observations were made of visual cleanliness and microbiological swabs taken from high-risk touch sites, such as the delivery bed and hand washing facilities. Information was collected on facility resources, infrastructure, and routine IPC practices. Interviews were conducted using ‘photo elicitation’ with a range of stakeholders to explore views and perceptions on the determinants and state of maternity unit hygiene.

Results:  Both within and between facilities, the determinants and state of hygiene varied, but all had room for improvement. In particular, no clear relationship was found between visual cleanliness and safety as assessed microbiologically through the presence of potential pathogens on touch sites, indicative of “hygiene failures.” Although knowledge of the importance of IPC was common, training was sporadic and some important cadres (ward cleaners or orderlies) were often excluded. Basic infrastructure for hand hygiene and sanitation was poor in some facilities, but for others this was not the case and yet hygiene remained poor, so highlighting human behavioural drivers.

Conclusion: Improvements in hygiene on maternity wards are important to the prevention of infections in mothers and newborns. This will become even more important as institutional deliveries increase. In-depth assessments using mixed methods are invaluable for informing and monitoring local and national level action.