The Impact of WASH on Maternal and Newborn Health: What Do We Know?

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: Oona Campbell, London School of Hygiene and Tropical Medicine

Background: The links between WASH and child health are well known, and are reflected in programme design. By contrast, recognition of WASH’s importance to MNH is nascent, and the evidence-base remains limited. This presentation contributes to this evidence.

Methods: We conducted a far-reaching exploratory literature review to develop a conceptual framework building on existing approaches to WASH-related disease classification, identification of health gender inequalities, and a life-course approach incorporating risk-accumulation and longer-term concerns.  We also conducted systematic reviews and secondary-data analyses to explore the association between water and sanitation (WatSan) and maternal mortality, and to describe WatSan for births in home and health-facility environments.

Results: There is suggestive evidence, supported by biological plausibility, that inadequate WASH may influence numerous (77) MNH outcomes, although many of these linkages are complex. Fourteen articles linked WatSan to maternal mortality. Most ecological studies of poor water or sanitation found an association with greater mortality, as did meta-analyses of adjusted estimates in individual-level studies. Data we subsequently analysed for Afghanistan showed households with unimproved water access had nearly twice the odds of pregnancy-related mortality (adjusted) compared to improved water access. We also found an association between unimproved toilet facilities and pregnancy-related mortality (OR = 2.3), but it was not statistically significant. However, we were unable to discern whether unimproved water source is a marker of unhygienic environments or socio-economic position.   We also established that many home births occur in poor WatSan environments, as do many facility births; therefore the potential population impact is large

Conclusion:  Many gaps remain requiring primary research to investigate specific exposure-outcome relationships and systematic reviews of existing evidence on the more dominant pathways. Nevertheless, whilst more evidence is needed, there is sufficient evidence to give greater consideration to WASH in in improving MNH, including in improving WASH in health facilities in the first instance.