PMNCH Knowledge Summary #30 Water, sanitation and hygiene - the impact on RMNCH*

Publisher: The Partnership for Maternal, Newborn and Child Health
Publication date: 2014
Language: English only


Introduction

Creating equitable and sustainable access to safe water and improved sanitation and hygiene (WASH) can dramatically benefit reproductive, maternal, neonatal and child health (RMNCH). Integrating WASH services and practices into health services delivery in health facilities and improving access to WASH within communities has been shown to decrease both morbidity and mortality of women and children. WASH interventions are cost-effective and have the potential to improve gender equality and human rights – crucial to the post-2015 development agenda – by giving women and girls more social freedom and safety, and removing inequitable work burdens. Creating multisectoral interventions that address WASH and RMNCH, and integrating WASH into existing frameworks and agendas for health, has the potential to bring about lasting and positive change for women, children, families and communities.

* The topic of water, sanitation, hygiene, and development is extremely diverse and goes beyond safe drinking water, sanitation and hygiene to the complex issues of water resource management and vector control for disease prevention. While all these topics are becoming increasingly important in the post-2015 agenda, this knowledge summary will focus on the narrower topic of water, sanitation and hygiene as it relates to RMNCH.

The challenge

There is a clear link between unsafe water, sanitation and hygiene, and detrimental health outcomes for women and children, especially in developing countries. Despite great advancements in reproductive, adolescent, maternal, neonatal and child health, increasing investments in WASH interventions may further improve the health and well-being of women and children. Yet WASH interventions are more than a means to improve RMNCH outcomes; they may also improve gender equality and human rights crucial to the post-2015 development agenda.1,2 Girls are disproportionally affected, missing school as a result of walking great distances to carry water for household use, as well as lacking adequate sanitation and hygiene facilities in schools to allow them to manage their menstruation.3 Further, inadequate WASH facilities are associated with sexual assault and gender based violence where toilets are unavailable or unsafe.3,4

Interventions and programmes that specifically target maternal and child mortality have made great advancements towards the achievement of Millennium Development Goals (MDGs) 4 and 5 (to reduce child mortality and improve maternal health). Inequitable progress on MDG 7c, (to halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation), especially for sanitation in rural areas and Africa, is holding back general development, equality and progress on other health-related MDGs such as reducing child and maternal mortality.5,6 Globally 8% of maternal deaths, and in developing countries an estimated 10-15%, are due to infections that can be directly linked to unhygienic conditions during labour and birth, at home or in facilities, and to poor hygiene practices in the six weeks after birth.7-9 Poor hygiene during and after umbilical cord cutting, such as unclean hands or use of dirty cloth, can produce significantly more cord site infections in newborns.10-12 Children from birth through childhood risk infections, illness, delayed development and reduced cognitive function as a result of unsafe water, poor sanitation and unhygienic practices.13-19. Approximately half a million children die every year of diarrhoeal disease caused by unsafe water and poor sanitation and hygiene practices.15,19 Fifty percent of global malnutrition is due to waterborne diseases such as diarrhoea and intestinal worms, and one quarter of stunting can be attributed to five or more episodes of diarrhoea before two years of age.20,21

Some recent progress has been made in recognizing the importance of WASH for broader health and development. The importance of WASH is increasingly recognized in global health frameworks such as the Global Strategy on Women's and Children's Health and the draft Every Newborn Action Plan.22,23 The framework provided under Universal Health Coverage also provides important opportunities to embed WASH into the key functions of the health system. Furthermore, the United Nations General Assembly, in resolution A/RES/58/217, proclaimed the period 2005-2015 International Decade for Action 'Water for Life.24

Despite this progress WASH is still often viewed as an infrastructure-led issue, the responsibility for which lies outside that of health systems. This perception goes handin- hand with the increasingly curative focus of the health sector and acts as a barrier to integration of WASH aspects in health strategies and programmes. In addition, the creation of a supportive enabling environment and the development and implementation of appropriate policies are an essential element of sustainable WASH programmes.25,26 Yet, many programmes do not strengthen policies or provide technical guidance to sector institutions and local stakeholders.25,26

What we know

Investment in women and girls is crucial for sustainable development. Creating equitable and sustainable access to safe drinking water, basic sanitation and promoting improved hygiene benefits the community at large, and women and children in particular. RMNCH programmes can see great improvements through the inclusion of WASH interventions. Access to improved water sources within the community can decrease maternal mortality by decreasing the risk of intestinal worms and thus anaemia and diarrhoeal diseases, which lead to nutritional deficiencies, and hepatitis.28 Decreasing the distance to safe water sources can support healthy pregnancy, by reducing the workload for women and supporting healthy weight gain, and is associated with decreased diarrhoeal disease in children.29

Improved WASH within hospitals and health facilities is also essential for improved RMNCH outcomes. Basic and simple hygiene practices during antenatal care, labour and birth, such as birth attendant hand washing and clean birthing surfaces, can reduce the risk of infections, sepsis and death for infants and mothers by up to 25%.9,28,30,31 This is particularly evident during the management of complications, such as caesarean or preterm delivery.9,28,30,31 Clean-birthing kits used for umbilical cord cutting can reduce the odds of cord site infections twofold.31,32

The combined benefit of hand washing, food hygiene and household hygiene reduces infant diarrhoea by more than one third, and safe excreta disposal can reduce the risk of infant diarrhoea by up to 37%.15,33 Improved drinking water sanitation and hygiene also lead directly to improved child growth and development.17,33

Box 1: Personal hygiene, shame and gender equality

Menstruating girls, due to lack of knowledge, cultural beliefs and inadequate hygiene facilities and supplies, may feel shame and social isolation resulting in poor self-esteem and decreased school attendance.19,35,36 The WASH Yatra project in India found that over 70% of girls did not know what was happening to their bodies when they began menstruation and regarded the process as dirty, leading to an increased sense of shame.3 Interventions that promote menstrual hygiene management (MHM) in broad settings, such as community, school and emergencies, can improve these conditions by creating available resources and information.35 Multisector approaches linking WASH with health, education and the private sector are essential to ensure that girls have access to MHM supplies, knowledge and the autonomy to improve personal hygiene practices.35

Box 2: Gender violence and WASH

Globally, 1 in 3 women risk personal safety and harassment due to inadequate and insufficient sanitation and hygiene facilities.19 In many parts of the world the only toilet facilities are communal and unmaintained, requiring that women have to use dirty and insecure toilets outside their household, sometimes with limited separation from those used by men.4,36-38 Studies conducted in India, Uganda and Kenya found that women were consistently afraid of sexual assault and rape, as well as physical violence if they tried to fight back.36-38 In each setting, women reported the shame due to the conditions around personal hygiene practices and helplessness to change their circumstances.36-38 The emotional toll, as well as the risk of violence and assault, is a stark reality for women living in conditions with inadequate WASH interventions.

What works

Multisector collaborations and investment in evidence-based interventions are essential for improving WASH and RMNCH outcomes.9 The private sector has great experience in behaviour change and innovation, while governments can develop enabling environments and ensure WASH infrastructures and budgets exist. Combined, these efforts can be highly beneficial in driving greater improvements in WASH access.19

Successful programmes collaborate across work-streams, engage communities and build on the strengths of existing programmes. Within health facilities, improved WASH requires wider health-systems strengthening with key links to areas such as quality improvement, patient safety, infection prevention and control, and health administration.9

At national level, coordination across ministries, partners and advocacy groups can ensure WASH interventions are included in RMNCH programmes. In Nepal, the Ministry of Health appointed a focal point to coordinate with the WASH sector to ensure that WASH was embedded within the Nepal Health Sector Support Programme (NHSSP II).39 The development of NHSSP II, and events like Global Handwashing Day, have brought together various ministries including those responsible for health, water, planning, works, education and local government, as well as UN agencies and civil society organizations.39

Integrating WASH into existing implementation frameworks can build upon the strength of established programmes. In Kenya hygiene interventions and education were integrated into the Expanded Programme on Immunisation services by either nurses or community health workers.40 Both delivery strategies led to an improvement in hygiene indicators such as knowledge and use of household disinfection of water.40 Both strategies also had great acceptance and uptake in rural and urban communities alike.40

Guidelines, frameworks and action plans, such as the integrated Global Action Plan for Pneumonia and Diarrhoea, Integrated Management of Childhood Illnesses (IMCI) and the community integrated version C-IMCI, provide comprehensive planning and implementation tools to address childhood illnesses including WASH interventions.23,41,42 In Democratic Republic of the Congo, Nicaragua, and Peru specific hygiene and WASH integrated C-IMCI programmes have been developed and implemented. These programmes found improvements in drinking water storage, hand washing, water handling and the decrease in diarrhoea after one year of programme implementation.42,43

Conclusion

The inclusion of WASH interventions and priorities in RMNCH programmes can bring about greater health improvements at community, health facility and individual levels. Including universal access to WASH in the post-2015 agenda can also help ensure that vulnerable and hard-to-reach communities and individuals gain access, and that WASH becomes a global priority. WASH programmes can also benefit from the inclusion of RMNCH priority agendas within programme planning and implementation, reaching the most vulnerable people experiencing the most detrimental effects of poor sanitation and hygiene, and improving health, equality and social justice. Investment in WASH, especially for hard-to-reach communities, has the potential to bring about lasting change.

References

1.JMP, WHO, Unicef. Ending Inequalities – a cornerstone of the post-2015 development agenda, 2013.
2.OHCHR, UN High Commissioner for human rights. Special Rapporteur on the human right to safe drinking water and sanitation. http://www.ohchr.org/EN/Issues/WaterAndSanitation/SRWater/Pages/SRWaterIndex.aspx
3.WaterAid. Making Connections: Women, Sanitation, and Health, 2013 http://www.sswm.info/sites/default/files/reference_attachments/Making_Connections__ Women_Sanitation_and_Health_290413.pdf
4.House S, Ferron S, Sommer M, Cavill S. Violence, Gender & WASH: A Practitioner’s Toolkit - Making water, sanitation and hygiene safer through improved programming and services. London, UK, 2014 http://violence-wash.lboro.ac.uk
5.UN Economic Commission for Africa. MDG Report 2013, Assessing Progress in Africa toward the Millenium Development Goals, 2013.
6.United Nations. The Millennium Development Goals Report 2012. New York, 2012.
7.Goodburn E, Campbell O. Reducing maternal mortality in the developing world: sector-wide approaches may be the key. BMJ 2001; 322: 917–20.
8.Gravett CA, Gravett MG, Martin ET, et al. Serious and life-threatening pregnancy-related infections: opportunities to reduce the global burden. PLoS Med 2012; 9: e1001324.
9.Simavi. Getting It Right: Imporving maternal health through water sanitation & hygiene, 2012.
10.Mosha F, Winani S, Wood S, Changalucha J, Ngasalla B. Evaluation of the effectiveness of a clean delivery kit intervention in preventing cord infection and puerperal sepsis among neonates and their mothers in rural Mwanza Region, Tanzania. Tanzan Health Res Bull 2005; 7: 185–8.
11.Darmstadt GL, Hassan M, Balsara ZP, Winch PJ, Gipson R, Santosham M. Impact of clean delivery-kit use on newborn umbilical cord and maternal puerperal infections in Egypt. J Health Popul Nutr 2009; 27: 746–54.
12.Mullany LC, Darmstadt GL, Katz J, et al. Risk of Mortality Subsequent to Umbilical Cord Infection Among Newborns of Soutnern Nepal. Pediatr Infect Dis J. 2009: 2: 17-20.
13.Department for International Development. Water, Sanitation and Hygiene; Evidence Paper, 2013 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/193656/WASH-evidence-paper-april2013.pdf
14.Action Against Hunger. Interactions of: Malnutrition, Water Sanitation and Hygiene, Infections, 2007.
15.Waddington H, Snilstveit B. Effectiveness and sustainability of water, sanitation, and hygiene interventions in combating diarrhoea. J Dev Eff 2009; 1: 295–335.
16.Clasen T, Roberts I, Rabie T, Schmidt W-P, Cairncross S. Interventions to improve water quality, particularly when implemented at the household level, are effective in preventing diarrhoea in settings where it is endemic. Cochrane Database Syst Rev 2009.
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18.Pickering AJ, Davis J. Freshwater availability and water fetching distance affect child health in sub-Saharan Africa. Environ Sci Technol 2012; 46: 2391–7.
19.WaterAid, Water Supply and Sanitation Collaborative Council, Unilever. We Can’t Wait; A report on sanitation and hygiene for women and girls, 2013.
20.Pruss-Ustun A, Bos R, Gore F, Bartram J. Safer water, better health, World Health Organization, 2008.
21.Walker CLF, Rudan I, Liu L, et al. Global burden of childhood pneumonia and diarrhoea. Lancet 2013; 381: 1405–16.
22.Every Newborn, An Action Plan to End Preventable Deaths. 2013. http://www.everynewborn.org/
23.World Health Organization, UNICEF. Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025: The integrated Global Action Plan for Pneumonia and Diarrhoea ( GAPPD ), 2013.
24.United Nations. International Decade for Action, “Water for Life”, 2005-2015 - resolution A/RES/58/217, 2005 http://www.un-documents.net/a58r217.htm
25.Rosensweig F, Perez E, Robinson A. Policy and Sector Reform to Accelerate Access to Improved Rural sanitation, 2012.
26.Perez E, Cardosi J, Coombes Y, et al. What Does It Take to Scale Up Rural Sanitation? 2012.
27.WHO, Unicef. Progress on Sanitation and Drinking Water: 2013 update. Geneva, Switzerland, 2013 http://www.wssinfo.org/fileadmin/user_upload/resources/JMPreport2013.pdf
28.Cheng JJ, Schuster-Wallace CJ, Watt S, Newbold BK, Mente A. An ecological quantification of the relationships between water, sanitation and infant, child, and maternal mortality. Environ Health 2012; 11: 4.
29.Wash Advocates. WASH: Strengthening Maternal, Newborn, and Child Health. http://www.washadvocates.org/learn/wash-facts/strengthening-maternal-newborn-and-child-health-through-wash/
30.Rhee V, Mullany LC, Khatry SK, et al. Maternal and birth attendant hand washing and neonatal mortality in southern Nepal. Arch Pediatr Adolesc Med 2008; 162: 603–8.
31.Blencowe H, Cousens S, Mullany LC, et al. Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect. BMC Public Health 2011; 11 Suppl 3: S11.
32.Blencow H, Lawn J, Graham W, Save the Children, Immpact. Clean Birth Kits – Potential to Deliver? Evidence, experience, estimated lives saved and cost, 2010 http://www.ohchr.org/EN/Issues/WaterAndSanitation/SRWater/Pages/SRWaterIndex.aspx
33.Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane database Syst Rev 2008; : CD004265.
34.Luby SP, Agboatwalla M, Feikin DR, et al. Effect of handwashing on child health: a randomised controlled trial. Lancet; 366: 225–33.
35.House S, Mahon T, Cavill S. Menstrual hygiene matters: A resource for improving menstrual hygiene around the world, 2012 http://www.wateraid.org/~/media/Files/Global/MHM files/Compiled_LR.pdf
36.Massey K. Insecurity and shame; exploration of the impact of the lack of sanitation on women in the slums of Kampala, Uganda. London, UK, 2011.
37.Amnesty International. Insecurity and Indignity; Women’s experiences in the slums of Nairobi, Kenya. London, UK, 2010.
38.Lennon S. Fear and anger; perceptions of risk related to sexual violence against women linked to water and sanitation in Delhi, India, 2011.
39.WaterAid. The sanitation problem: What can and should the health sector do? London, UK, 2011.
40.Ryman TK, Briere EC, Cartwright E, et al. Integration of routine vaccination and hygiene interventions: a comparison of 2 strategies in Kenya. J Infect Dis 2012; 205 Suppl : S65–76.
41.WHO. Integrated Management of Childhood Illness (IMCI). 2012. http://www.who.int/maternal_child_adolescent/topics/child/imci/en/index.html
42.CORE Group, USAID. C-IMCI Programme Guidance, 2009.
43.Group TM. Hygiene behavior change as part of community child health. 2013. http://www.manoffgroup.com/WASHandC-IMCI.html

Acknowledgements

Scientific writer: Katherine Theiss-Nyland. Contributors for development and review: Bilal Avan, Claire Chase, Rebecca Fishman, Wendy Graham, Peter Harvey, Sarah House, Carolyn Jones, Joy Lawn, Julia Lloyd, Analia Mendez, Helen Petach, Emily Rand, Joanna Schellenberg, Kadidiatou Toure, Yael Velleman. Coordinating team: Bilal Avan, Agnes Becker, Shirine Voller, Deepthi Wickremasinghe, at the London School of Hygiene and Tropical Medicine, and Vaibhav Gupta, Shyama Kuruvilla, Elizabeth Noble, Kadidiatou Toure, at the Partnership for Maternal, Newborn and Child Health. Design by: Roberta Annovi.

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