WASH For Mothers: Importance of clean water and sanitation during pregnancy
The following post is part of a series of posts exploring water, sanitation, and hygiene (WASH) and maternal health. It is written by Grace Kodindo, an obstetrician-gynecologist from Chad, currently serving as RAISE Medical and Advocacy Advisor at Columbia University’s Mailman School of Public Health. To read other posts in the series, click here.
Worldwide, 1.1 billion People live without clean water and 2.6 billion people lack adequate sanitation (2002, WHO/UNICEF 2004). What we need to understand is that water–related diseases do have specific impacts on maternal health and pregnancy outcomes. First of all, water has a physiological impact on the development of a normal pregnancy. Maternal hydration allows both mother and fetus to react to changes in order to keep conditions in the body, for example temperature, the same. Drinking water influences the amniotic fluid volume, fetal well being and removes toxic products.1 Lack of access to clean water and living in environment with dirty stagnant water are known to result in largely preventable water–related diseases that can lead to severe impact adverse pregnancy outcomes. Those diseases are malaria, typhoid, chronic hookworm infestations like ankylostomiasis, dysentery, cholera, giardiasis, amoebiasis, etc.
Studies in countries with endemic typhoid have shown that typhoid fever can lead to spontaneous abortion, fetal death and maternal complications with death where there is no appropriate antibiotic treatment.2
About 20–30% of pregnant women in Sub-Sahara Africa are infected with hookworms by walking or bathing in contaminated water and thus are at risk of preventable hookworm-related anemia. Anemia increases their risk of dying during pregnancy and delivering low birth weight babies who in turn are also at risk of dying.4
Access to clean water is also an essential part of infection prevention in maternal care services. Proper hand washing is one of the most effective ways to reduce the spreading of infection in health care settings. HIV, tetanus bacterium and many others infectious agents can be introduced to the uterus by contaminated instruments or hands during deliveries performed under unhygienic conditions procedure. To encourage hand washing, program managers should make sure that soap and a continuous supply of clean water is available. Since clean water and basic sanitation are so closely related to healthy pregnancy outcome, how can they be integrated? They were integrated in the beginning because in the declaration of Alma Ata in 1978, clean water, basic sanitation and maternal and child services have been outlined as components of the Comprehensive Primary Health Care strategy of “Health For All” (WHO,1978). WASH and maternal health interventions should be integrated through the comprehensive primary health care approach so that governments and their partners could implement them together as long term strategy for maternal and child health. Countries like China, Indonesia Bangladesh, Cuba, Kerala state in India, have implemented successfully the comprehensive primary health care with well reported impact on improved maternal and child health.5
Clearly pumped ground water will provide safer water compared to unprotected surface water, like non covered wells or contaminated rivers where people bath and draw drinking water. Pumped water may be more affordable in poor household who cannot afford piped water. At the moment, any evidence to suggest that pumped water lead to better maternal and children outcomes has maybe not been well documented. Pumped water is clean water and it has been proved to prevent water born diseases but I must say that there are needs for more data on the relation of pumped water and adverse maternal health and pregnancy outcomes. Much more studies have been done on chlorination disinfection by-products such as Trihalomethanes (THMs) and chlorinated solvents such as trichloroethylene (TCE). Studies on THMs and adverse effects provide moderate evidence for association with small for gestation age (SGA), neural tube defects and spontaneous abortion but other solvents were not studied, so the evidence for association was weak.6 The authors recommended larger scale, national longitudinal study enrolling children prenatally during the first trimester and following them until the adolescence.
Advocating for clean water should be a top priority. For billions of people the MDG7 goal may be far from reach. It is of course a matter of human right, human dignity and of equity. Affordable and accessible clean water lead to better health and better life for mothers. Healthy mothers, liberated from the burden of walking long distance to fetch water can be more productive and more able to pay for the installation and maintenance of clean water supply. They can be powerful tools in advocacy efforts for more clean water and sanitation supply for all.
1. Tomasz, N “The Statement of Polish Gynecological Society experts concerning drinking water consumption in women in reproductive age, pregnancy and breastfeeding”, Ginekol Pol, July 2009, 80(7).
2. Carles, G “Fievre typhoide et Grossesse”, Journal de gynecologie obstetrique et Biologie de la reproduction, Septiembre 2002, vol 31 Nº 5.
3. Steke R W et al., “The burden of Malaria in pregnancy in malaria endemic areas” Am J Tropical Med Hyg 2001.
4. Booker, S et al. “Hookworms related Anemia among pregnant women: A systematic review”, PLOS Negl Trop Dis 2 (9)e 201.doi 101371/journal.prntd.0000291, 2008.
5. Magnessum, L et al, “Comprehensive versus Selective PHC: Lessons for Global H Policies”, Health Affairs, 2004 vol23 Nb1.
6. Bove, F. et al., “Drinking water contaminant and Adverse pregnancy outcome: A review”, Division of Health Studies, Agency for Toxic Substances & Diseases Registry, Atlanta, Georgia, USA, 2002. Environmental Health Perspectives V.110 (suppl 1) Feb 2002.