The global health community has seen substantial reductions in deaths from “the big three” infectious diseases: HIV/AIDS, malaria, and tuberculosis; as well as an almost 50% reduction in under-five child deaths from 1990 – 2012. . This progress is due in part to the Millennium Development Goals (MDGs), which identified combatting transmission of HIV and malaria and premature death from these diseases (MDG 6), and a 2/3 reduction in under-five child deaths (MDG 4) as primary global health concerns. Unfortunately, this progress has not extended to mothers and newborns, as maternal and neonatal deaths are decreasing at a much slower rate than under-five deaths and deaths from infectious diseases [4, 5]. As a result, MDGs 4 and 5 remain unfinished.
The post-2015 Global Goals for Sustainable Development (Global Goals) have incorporated the unfinished MDG agenda into their mandate, pledging to reduce the incidence of maternal deaths, end preventable newborn and child deaths (SDG 3) as well as achieve equitable access to safe drinking water and improved sanitation (SDG 6).
Two PLOS Medicine articles have identified access to improved water, sanitation, and hygiene (WASH) as a pathway to reduce adverse pregnancy outcomes (APOs) and preventable deaths in mothers and newborns. In the 2014 article, From Joint Thinking to Joint Action: A Call to Action on Improving Water, Sanitation, and Hygiene for Maternal and Newborn Health, authors collaborated with UN agencies and academic institutions on a call to action for stakeholders to prioritize WASH for maternal and newborn health. In the 2015 article, Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study, authors conducted the first population-level study that found poor sanitation and open defecation is associated with APOs.
Yet, in spite of this evidence showing improved WASH will positively impact maternal and newborn health (MNH) this global health challenge has not been championed adequately by stakeholders.
To discuss the importance of prioritizing WASH for maternal and newborn survival, PLOS Medicine authors Yael Velleman (WaterAid), Oliver Cumming (London School of Hygiene and Tropical Medicine), and Pinaki Panigrahi (Univ of Nebraska Medical Center) will be participating in this week’s ‘PLOS Science Wednesday’ redditscience ‘Ask Me Anything’. They will be answering your questions about how limited access to WASH leads to inequitable health outcomes, particularly for mothers and children, the broader impacts of this global health challenge, its positioning on the global health agenda on redditscience at 1pm ET (10am PT) on Wednesday October 28, 2015. You can register on redditscience in preparation for this upcoming AMA (or on the day of), so you’ll be able to add your questions and comments to the live conversation.
In From Joint Thinking to Joint Action: A Call to Action on Improving Water, Sanitation, and Hygiene for Maternal and Newborn Health, authors Velleman and Cumming outlined five important steps the global health community can take immediately to begin to alleviate the burden of inferior WASH, which include: (1) Implement World Health Organization (WHO) strategy on WASH in health care facilities; (2) Implementing the WHO Every Newborn Action Plan (ENAP); (3) Embed WASH in national and international monitoring frameworks for Universal Health Coverage (UHC); (4) Embed WASH in the post-2015 Global Goals framework; (5) Allocate financial resources to WASH as a core health strategy.
In Panigrahi and colleagues’ recent article, Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study, researchers found that practicing open defecation while pregnant resulted in a much higher risk of experiencing APOs, including preterm birth, low birth weight, spontaneous abortion, and stillbirth. This is the first study that was able to link poor sanitation practices, due to limited access to improved WASH facilities, to APOs.
The evidence outlined in both PLOS Medicine studies shows that to improve maternal and newborn health (SDG targets 3.1 & 3.2) by 2030, the global health community must first ensure equitable access to improved WASH (SDG 6), particularly for vulnerable women and girls (SDG 6.2). It is essential that improved WASH be prioritized alongside other global health measures intended to prevent unnecessary deaths for mothers and newborns.
To learn more about WASH for maternal and newborn health, read the following PLOS articles by our participating authors:
1. What has been some of the progress made in WASH for MNH since this paper was published in 2014?
Yael: There has been some encouraging progress; in March 2015, WHO and UNICEF released the first ever global report on WASH in healthcare facilities (data from 54 countries), and then convened a special meeting on WASH in healthcare facilities in Geneva, including research partners, donor governments and country representatives, with a strong focus on WASH in maternity units. The meeting has resulted in a draft Global Action Plan on WASH in healthcare facilities, and the setting up of several task teams to take forward work on this, in terms of research, global and facility-level monitoring, and advocacy. Importantly, the initiative involves several WHO departments including maternal and child health, universal health coverage, patient safety and WASH. In May 2015, a side event on the same topic was hosted by WaterAid, the WHO and the governments of Zanzibar and Bhutan at the World Health Assembly. WASH also features strongly in the new Global Strategy on Women, children and Adolescent Health, and was discussed at the Global Conference on Maternal and Newborn Health just this past week in Mexico City.
Oliver: On the research and evidence side, there is growing interest among academics from different fields in understanding how poor WASH conditions at home and in health facilities influence maternal and newborn health outcomes. Since this paper was published, a number of new studies have been initiated and new results have been published. As will be discussed during the AMA session next week, a paper by Das and colleagues published in PLOS Medicine earlier this year is the first study to rigorously assess the association between poor sanitation access among pregnant women and adverse pregnancy outcomes.
Naturally, this is only the beginning and there is still much work to be done, especially at national level to secure concrete progress.
2. SDG 6 is devoted to improving the availability and sustainability of clean water and sanitation with a target specifically focusing on vulnerable women and girls (“By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations”). Do you feel this target in SDG 6 is sufficient? Do you anticipate this goal will be successful even without a specific, measurable target?
Yael: I’m not an expert on this but I feel there are some crucial gaps here, particularly in the proposed indicators framework. For example, there is no specific indicator on availability of WASH in healthcare facility, and none on measuring improvement in hygiene. This is problematic since monitoring of WASH in healthcare facilities is a simple way of ensuring an integrated approach that recognizes WASH as part and parcel of delivering Universal Health Coverage. Since “what gets measured, gets done,” this can hamper efforts to improve the situation. In terms of overall access to water and sanitation, I agree that a gender focus is very important but at the monitoring level, it is very difficult to disaggregate data by gender. Therefore, a specific measure of women’s access to WASH may not be helpful.
3. In this paper, you outline five key steps that the global health community can start with immediately. Have we seen progress toward achieving these goals? If so, what have been some of the health impacts on these policy changes? If there has not been progress, what are some of the barriers to implementation?
Yael: Step 1: Support and implement the forthcoming WHO strategy on WASH in health care facilities
As noted earlier, there has been progress on this and it’s encouraging to see the effort get real traction within WHO as a whole, and among donor countries like the US and UK. But as I said, we’re just at the start of the process and momentum needs to be sustained.
Step 2: Support the implementation of the WHO Every Newborn Action Plan (ENAP) in its entirety, with a specific emphasis on WASH:
ENAP itself was quite strong on WASH overall – although some aspects could have perhaps been better-linked. I think it’s a little early to see the impact that this is having on the ground, and the process of defining national ENAP roadmaps has been slow to begin. I’m afraid I’m not sure I can judge at the moment whether there is good progress on this step or not.
Step 3: Embed WASH in national and global implementation and monitoring frameworks for Universal Health Coverage
Yes and no… the first global UHC monitoring report came out, and household access to water and sanitation was used as one indicator, which is great. But the report didn’t include WASH in healthcare facilities, which is an important flaw. It is perhaps understandable at this stage since there is so little data, but it is problematic since including an indicator on this would be helpful to actually ensure that data is collected. This is something we’re hoping to address with the World Bank (who issues the report together with WHO) in the next few weeks. At a country level, I think there is not yet an agreed monitoring framework on UHC, and that this will be taken up as part of the SDG monitoring process at country level (under Goal 3).
Step 4: Embed WASH in the post-2015 development framework
Yes this happened (see Question 2) – but with the above caveats in terms of what’s being measured.
Step 5: Ensure adequate financial resourcing to WASH as a core health strategy
I think we can confidently say this is way behind, although I can’t give you any figures (and we didn’t set a benchmark in the paper or made any cost estimates).
4. What are some of the available WASH interventions, programs or policies that can be readily implemented in most places that will lead to improved health outcomes for mothers and children?
Yael: Running water and functioning handwashing stations with soap and water in healthcare facilities would be a good start! And are absent in so many facilities. The data from the WHO/UNICEF report is quite shocking – 38% of facilities don’t have access to improved water source, and even that is often outside of the facility and not piped into the facility (which makes a big difference in terms of infection prevention and control). At household level, a functioning toilet and access to a constant supply of water, as well as good environmental sanitation to protect public health are all well-known basic interventions that are often absent, perhaps Ollie can add more here, but the data is just as discouraging as ever: 2.5 billion people don’t have access to improved sanitation, more than a billion practice open defecation.
Oliver: On the domestic side — I would flag the large deficit on household level access to water (i.e. not just a water source within a km of the HH which was the de facto norm for ‘improved water’ under the MDGs), which is as bad as sanitation. Our 2014 PLOS ONE paper, “Does Global Progress on Sanitation Really Lag behind Water? An Analysis of Global Progress on Community- and Household-Level Access to Safe Water and Sanitation” estimated that 2.35 billion people are without access to water at home. With regard to domestic births, I would say that the key is having household level water and sanitation and approximately 2.5 billion people are without this.
Do you have more questions about WASH interventions for maternal and newborn health? Yael Velleman and co-authors Oliver Cumming and Pinaki Panigrahi will be taking your questions on redditscience on October 28, 2015 at 1pm ET!