From Joint Thinking to Joint Action: A Call to Action on Improving Water, Sanitation, and Hygiene for Maternal and Newborn Health

Summary

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Water, Sanitation, and Hygiene, and Maternal and Newborn Health: An Opportunity for Progress

The “deep dark and continuous stream of mortality” lamented by William Farr in 1876 when describing maternal mortality statistics in England [1] continues in many parts of the world today, and for some families, childbirth is as much a risk of death as a moment of life. Progress has been slow compared with other areas of public health, and geographically and socio-economically unequal; maternal and newborn health (MNH) remains a major global challenge [2],[3].

Newborn mortality has decreased more slowly than overall under-five mortality, and accounts for a median share of 44% of under-five mortality in high-burden countries [4]. Between 1990 and 2012, newborn mortality declined by only 37% from 33 to 21 deaths per 1,000 live births, compared with a more impressive 50% reduction in under-five mortality over the same period [4]. Progress on reducing maternal mortality has been even slower and more uneven across countries, with a median annual rate of reduction in high-burden countries between 2000 and 2013 of 3.1% [5]. Whilst the maternal mortality ratio (maternal deaths per 100,000 live births) has fallen globally from 380 to 210 since 1990 [6], these figures mask wide disparities. In 2013 the average maternal mortality ratio in developed countries was 16 per 100,000 live births compared with 230 in low- and middle-income countries (LMICs) [6]. This chasm separating the prospects of women giving birth in one part of the world as compared with another is what Halfdan Mahler, then Director General of the World Health Organization (WHO), described in 1987 as “the largest discrepancy of all public health statistics” [7].

Many calls have been made for wider and better-coordinated efforts to leverage increased resources and more effective action on MNH [8], particularly in low-income, high-burden settings [9]. Linking investments in water, sanitation, and hygiene (WASH) presents an overlooked but potentially important opportunity for progress. WASH—defined as improved water quantity and quality, sanitation, and hygiene—can prevent or limit the transmission of disease through multiple routes [10],[11]. As a sector, WASH spans a broad range of interventions, from campaigns to promote sanitation and hygiene behaviours, to water and sanitation infrastructure, to regulation of service quality and cost of drinking water or sanitation services [12].

A lack of coherence between sectors and programmes has been implicated in the poor progress on some Millennium Development Goals (MDGs) and targets (see Box 1), including the MDGs for maternal and child health [13]. Coordination between the WASH sector and the health sector is challenging; opportunities for better integration have been identified [14], although the focus is often on child health rather than maternal or newborn health [15]. Recently, growing concern about health care-associated or nosocomial infections has increased attention to hygiene in health care facilities under the “Clean Care is Safer Care” banner of the WHO Patient Safety initiative [16],[17]. The WHO guidelines on hand hygiene in health care facilities also recognise the importance of water and, to a lesser extent, sanitation as determinants of safe hand hygiene [18].

Significant progress has been made on extending access to water under the MDGs, with less progress on sanitation [19]. The MDG target on water and sanitation did not include access to WASH in health care facilities and other settings where births occur [20]; this has impeded the potential contribution of WASH to MNH efforts.

This collaborative paper by academics and representatives from international WASH and MNH agencies urges action and offers recommendations to accelerate WASH service provision at home and in health care facilities to improve MNH.

The Potential Contribution of WASH Efforts to Maternal and Newborn Health

Historically, the connection between WASH and MNH is well established [21]–[23]. In 1795, Alexander Gordon (1752–1799) asserted that deaths from puerperal fever could be prevented with greater cleanliness and that “nurses and physicians ought carefully to wash themselves” after contact with an infected patient [21]. Ignaz Semmelweis (1819–1865) later achieved a dramatic reduction in maternal deaths by requiring doctors to wash their hands in chlorine solution before examining women in labour [24].

By modern standards, there is a dearth of rigorous research to quantify the effects of WASH interventions on MNH outcomes. A recent systematic review of the association between water and sanitation environments and maternal mortality found only 14 relevant studies, none of which were intervention studies [25]. Although all studies had limitations, a pooled analysis of those linked at an individual level (case-control design) found that poor water and sanitation access was associated with higher levels of maternal mortality. A study by Gon and colleagues showed that unimproved household water access was an important risk factor for pregnancy-related mortality in Afghanistan [26].

Although no systematic review could be identified on the effect of WASH on neonatal mortality, a recent systematic review and Delphi estimation found that “clean birth practices” in both homes and facilities were associated with reduced all-cause, sepsis and tetanus neonatal deaths [27]. The review did not consider water and sanitation access in birth environments, but eight observational studies concerning handwashing with soap by birth attendants were included and all were consistently protective for neonatal sepsis and cord infection [27]. One cohort study in Nepal found that birth attendant and maternal handwashing were protective against neonatal mortality, with a 41% (95% CI 6%–63%) lower mortality rate among neonates exposed to both practices [28].

The Current Challenge

While the importance of hygiene is increasingly being recognized, far less consideration has been given to the role of the complete WASH package in relation to MNH outcomes in both home and facility birth settings. A recent WHO rapid assessment of WASH coverage in health care facilities in 54 low-income countries found that 38% of these facilities lacked an available improved water source [29]. In some low-income settings, many more women give birth in domestic environments than in health care facilities, and these are often without any basic water and/or sanitation. Figure 1 shows estimates for the proportion of births that occur in homes without improved water and/or sanitation for four countries (Bangladesh, India, Malawi, and Tanzania) [30]. These countries were selected as they are the focus for an on-going research programme (the SHARE research consortium); they also provide case studies from the two regions that have the lowest levels of WASH coverage and highest maternal and neonatal disease burden (sub-Saharan Africa and South Asia). In all four countries, only a minority of home births occur in environments where adequate water and sanitation are available. This is of major importance in low-income settings where the burden of health care-associated infections is potentially much higher [31], as is maternal and newborn mortality.

Efforts to improve birth conditions in low-income countries have tended to focus on specific measures for maternity care, health system strengthening, and increasing women's demand for giving birth in health care facilities [32],[33]. Little attention has been paid to the conditions in which births take place. Increasing the use of health care facilities for childbirth without considering the availability and quality of WASH in these facilities may limit potential health gains. Current WHO recommendations on postnatal care for mothers and newborns [34] include only one reference to WASH, which relates to the need for counselling women on hygiene. The guidelines for the Standards for Maternal and Neonatal Care [35] include no recommendations on WASH service provision. The six essential “cleans” proposed by WHO during childbirth imply the importance of WASH but are not explicit [35]. Inevitably, health care facilities are often managed around the provision and improvement of diagnostic and treatment services, and WASH may be such an obvious requirement that it is insufficiently emphasized in national health standards and monitoring instruments. This neglect is compounded by the lack of clarity on who—within the overall structure of the health system and in individual health care facilities—should be responsible for ensuring adequate WASH provision.

Beyond the increased risk of infection where WASH is absent, a lack of drinking water or availability of safe sanitation facilities in hospitals and clinics may discourage women from giving birth in these facilities and/or contribute to delays in seeking care. The absence of basic WASH infrastructure in health care facilities may also contribute to staff absenteeism as has been found in studies from India, Indonesia, Uganda [36], and Bangladesh [37]. Further, as noted in the 2006 World Health Report, “no matter how motivated and skilled health workers are, they cannot do their jobs properly in facilities that lack clean water…” [38].

The MDGs—especially MDG5 on improving maternal health—have certainly created momentum, by emphasising the need for explicit programmes to improve maternal health. However, their siloed nature has left little room for much needed cross-sectoral collaboration and comprehensive, integrated programming across the continuum of care. The absence of targets on water and sanitation services in strategies for achieving MDGs 4 and 5 has constrained progress on reducing maternal and newborn mortality. While the drive to increase women's demand for delivering in health care facilities is needed, the benefits for MNH are compromised if these cannot provide even minimum sanitary and hygiene standards.

A Vision for Improved Maternal and Newborn Health through Improved WASH: What Would Change Look Like?

The multiple and interrelated causes of maternal and newborn deaths each require a number of interventions [39], and no single intervention will reduce mortality significantly. Nonetheless, as WASH underlies many of the determinants as well as responses to MNH, it is an important part of a well-functioning health system that harnesses synergies between different interventions and responds effectively to MNH challenges. Box 2 details some of the lessons that can be learned from the education sector in terms of improving cross-sectoral action.

The current debate on formulating a post-2015 development framework to replace the MDGs provides an opportunity to redress the currently fragmented approach to improving MNH. For a new framework to be successful it must embed time-bound targets on the underlying determinants of poor MNH outcomes, as well as the quality of services, in any new goal on improving these outcomes. This must include targets on WASH at household and facility level, and provide for cross-sectoral coordination, and joint planning, investment, and monitoring to achieve goals and targets. The recently launched WHO Every Newborn Action Plan and its accompanying WHO Quality Initiative provides a useful example of the practical application of such an approach [40].

Building a Context for Change: Target-setting and Monitoring

A change in the way systems operate requires a change to the targets against which their performance is measured. An integrated approach to MNH will therefore require targets and indicators that mainstream WASH considerations.

Targets and indicators

What little time remains until the “expiry” of the MDGs should be used to maximise the potential for reaching MDG targets on MNH. Several agencies have committed to renew efforts on maternal, newborn, and child health before 2015; the World Bank, UNICEF, and Norway have announced a US$1.1 billion contribution towards meeting MDGs 4 and 5. Targeting these new resources towards ensuring that all facilities in which deliveries take place have adequate WASH provision will allow immediate action on the gaps identified in this paper. The WHO's “Essential Environmental Health Standards in Health Care” issued in 2008 (Box 3) set out what adequate provision means, and all efforts should strive towards their implementation.

Adequate targets and indicators should be formulated within the post-2015 framework. As a starting point, building on the emerging consensus among stakeholders involved in discussions on a post-2015 agenda for WASH, a target to achieve universal (total) access to WASH by 2030 is ambitious yet realistic. This target includes complete access in institutions and public spaces, such as health care facilities (see Box 4). Although such a target will be important for galvanising political will and investment, it will not on its own challenge the often siloed approach prevalent under the MDGs in which WASH is seen as separate to health, and therefore not an area of shared responsibility across sectors. Therefore, in addition to a target on universal coverage, the post-2015 framework should embed specific targets and/or indicators on access to WASH under goals and targets on improving health outcomes such as MNH. For example, a goal on reducing maternal mortality can include indicators on household water and sanitation access (determinants), as well as on WASH provision in delivery facilities (services).

Further, WASH indicators can be incorporated into certain elements of the Universal Health Coverage (UHC) framework, which has featured prominently within discussions on health in the post-2015 framework (see Box 5). UHC includes universal population coverage, financial risk protection, and a package of services comprising prevention (including environmental health and behaviour change promotion) and treatment (curative and rehabilitative/palliative) elements. A target on UHC can include WASH elements both under prevention aspects (e.g., monitoring WASH access indicators at the community level and linking to MNH service planning, and incorporation of hygiene and sanitation promotion within health programmes), and treatment aspects (e.g., adoption and implementation of WASH standards for health care facilities in terms of both infrastructure and practices).

Monitoring progress indicators on WASH access and quality of care

A successful international framework that adequately addresses MNH must be accompanied by a robust system for gathering information and monitoring progress. An essential step toward the inclusion of WASH indicators in relevant monitoring frameworks will involve WASH facility monitoring within the health care delivery environment. WASH indicators currently captured in national emergency obstetric and newborn care needs assessments include the presence of a water filter or other means to make potable water available to patients and staff; functioning running water supply; and availability of chlorhexidine (proxy for disinfectants and antiseptics) [41]. However, this information is often inadequately and inconsistently captured in existing monitoring frameworks.

There are several ways to address this shortcoming. Firstly, existing data and methods for data gathering can be used more effectively. For example, using Tanzania as a case study, Benova and colleagues suggest a method through which available survey data could be used to estimate the water and sanitation environment of home and facility birth settings [30]. The authors used existing household and facility survey data to characterise home and facility birth environments as water and sanitation (WATSAN)-safe or -unsafe, and to describe the proportion of all births (home and facility) occurring in a WATSAN-safe environment. On average, 44% of health care facilities that conduct deliveries were WATSAN-safe but only 24% of delivery rooms within these facilities were WATSAN-safe. Furthermore, even if all home births took place in facilities, only 59% of all births would occur in a WATSAN-safe environment. The approach used for the analysis of the Tanzania data showed that it is possible in this way to estimate the WASH conditions under which births take place at home and in health care facilities, and that existing data collection mechanisms can be used without the need for significant redesign. Small adaptations in the ways in which data are interpreted can also help identify geographic disparities in access to WASH to assist in planning and budgeting processes. Such aspects can be incorporated into existing global monitoring platforms such as the WHO/UNICEF Joint Monitoring Programme (JMP) on Drinking Water and Sanitation [42] and Countdown 2015 [5].

Secondly, existing instruments can and should be improved to deliver on a more ambitious MNH agenda. The Service Availability Readiness Assessment (SARA) tool could help identify where the need is the greatest, but it must be strengthened in order to do so. At present, SARA evaluates a facility's water provision only; future iterations should include all relevant WASH aspects in and adjacent to maternity facilities, for staff and for patients. Recent efforts by WHO and partners to develop a global strategy on WASH in health care facilities [43] are encouraging in this respect and should be backed up with international and national support. The strategy will aim to encourage country implementation of existing standards [44] and good practice; promote expanded monitoring of WASH in health care facilities, including through strengthening existing instruments like SARAs; and based on this evidence, carry out advocacy to reverse the neglect of this crucial service quality aspect. This strategy links with efforts to ensure minimum basic infrastructure and hygiene services, including access to energy and health care waste management. The strategy will be accompanied by a specific action plan committed to by participating stakeholders. This promising new initiative should complement and bring together relevant WHO programmes and strategies such as Family Health (including MNH), health systems strengthening, and Patient Safety (covering health care acquired infections and Infection Prevention and Control).

Delivering Good Maternal and Newborn Health through Linkages to WASH: Taking Action

Given the proven as well as potential links between WASH and MNH, we argue that an increased focus on WASH can pay dividends in terms of improved service quality; this in turn can contribute to improvements in service utilisation, and ultimately better health outcomes. It is clear that there is no time to lose given the relatively slow progress on MNH, and that current approaches insufficiently address the magnitude of the challenge. As shown in the Sierra Leone case study in Box 6, much can be achieved even in a resource-constrained and challenging environment.

There are important steps that can be taken immediately by the international and national community to address the issues raised in this paper:

• Support and implement the forthcoming WHO strategy on WASH in health care facilities: We welcome this initiative and urge donors, national governments, and other agencies to adopt the proposed actions, and implement the existing standards as part of overall national action to reduce maternal and newborn mortality. Implementing the strategy will entail firstly high-level political recognition that WASH is a critical component of MNH strategies. Secondly, it will require reorienting management and budgeting priorities and standards to include the necessary infrastructure and supplies, training, and monitoring. Thirdly, simple, low-cost practices should be applied at the facility level to maintain basic hygiene and sterile conditions, particularly in delivery rooms and operating theatres.

• Support the implementation of the WHO Every Newborn Action Plan (ENAP) in its entirety, with a specific emphasis on WASH: We welcome this plan and its comprehensive attention to all aspects contributing to newborn health within and outside of health care facilities. ENAP includes attention to household access to water and sanitation, WASH within the domains of quality-of-care for maternal and newborn care and infection prevention and control, and the importance of cross-sectoral action to improve newborn health. The inclusion of WASH interventions in the Every Mother Every Newborn Quality Initiative [45] will be critical for the Initiative to be effective. To ensure that the ENAP and related initiatives result in improved MNH outcomes, they must be translated into national roadmaps that adequately reflect the role of WASH in terms of financial and human resourcing, monitoring systems, and training of health care staff; and that link MNH efforts to existing national plans and programmes to improve access to WASH and improve public health.

• Embed WASH in national and global implementation and monitoring frameworks for Universal Health Coverage: The drive to achieve UHC is a unique opportunity to redress the neglect of public health in recent decades, as it positions prevention and treatment side by side as core components of a well-functioning health system. WASH is crucial for the success of the UHC model as it contributes to both preventive and treatment aspects and is a core component of quality of care. Any global and national monitoring frameworks on UHC should include performance indicators on access to WASH at household and health care facility levels and across all health services. Data on these performance indicators should be routinely collected, shared, and used to plan and prioritise actions and resources.

• Embed WASH in the post-2015 development framework: In this paper we proposed the various ways in which WASH should be built in to the new development framework. This integration is a crucial opportunity to address the shortcomings of existing goals and targets and encourage cross-sector action to improve health outcomes through addressing WASH in both domestic and health care facility settings. We call on all stakeholders engaged in discussion on the post-2015 development framework at all levels to ensure that the framework includes a dedicated goal on universal access to WASH, and that the framework is adequately structured to reflect the need for cross-sectoral action by embedding WASH aspects in the proposed health goals and targets.

• Ensure adequate financial resourcing to WASH as a core health strategy: the recognition of the importance of WASH as a determinant of MNH and a crucial part of MNH services should be reflected in terms of targeting and monitoring of financial resources. Resourcing should take into consideration not only the capital costs of infrastructure but also aspects of sustainability, accessibility, and affordability, at household and health care facility levels. These resources should include more and better-targeted investment in water and sanitation infrastructure in national budgets as well as a redoubling of efforts to meet access targets towards achieving universal access by 2030. Aid policy and financial channels should be adjusted to enable the use of aid resources to implement multi-sectoral and integrated MNH plans and programmes.

Many additional, specific actions can and should be taken by governments, health care providers, donors, the research community, and advocates from civil society and health care user groups. These are set out in Table 1.

Conclusions

Many of the challenges highlighted in this paper can be seen as opportunities. The actions we propose are achievable and offer significant positive externalities beyond the health of mothers and newborns. The timing for action is favourable. The opportunity to develop an improved international development framework is one good reason. Another is the increased acceptance, demonstrated by the publication of this paper and the broad coalition of stakeholders that contributed to it, of the need for cross-sectoral action. The prospect of bolder and more ambitious goals on health and WASH replacing the existing MDG targets offers an opportunity that should not be missed to create a broad-based effort to address the slow progress on MNH and mortality, and help address the unequal burden of maternal and newborn mortality borne by high-burden countries, and the poorest and most at-risk populations globally.

Although further research is required to increase our understanding of the specific direct and indirect mechanisms that link WASH and MNH, to quantify the effects of particular interventions on specific maternal outcomes, and to assess the relative importance of different interventions in different settings, there is sufficient knowledge to justify action. The pursuit of further knowledge should be done in conjunction with, and not prior to, the actions proposed in this paper. While these links are complex and difficult to quantify, there should be no argument with the fact that women worldwide are entitled to clean, safe, and dignified environments during pregnancy, childbirth, and the postpartum period. It is also clear that any investment aimed at improving MNH through better WASH facilities at home or in health care facilities will yield positive externalities for the wider population, including children and other family members at home, and other patients and medical staff or care-givers in health care facilities. The neglect of this basic human right continues to frustrate global efforts to improve MNH.

We call on governments and other agencies to implement the measures described in this paper; and we call on health care staff and members of the public to demand universal access to acceptable and dignified health services, and sustainable, accessible, and affordable water and sanitation services. All of us must play our roles in securing a cleaner, safer, and healthier future for all mothers and newborns.