WASH for Mothers: Using Clinic Based Care to Bring Safe Water to Mothers

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By: Anangu Rajasingham, US Centers for Disease Control and Prevention

The following post is part of a series of posts exploring water, sanitation, and hygiene (WASH) and maternal health. It is written by Anangu Rajasingham from the US Centers for Disease Control and Prevention in Atlanta, Georgia. To read other posts in the series, click here.

Over 900 million people worldwide do not have access to an improved water source.1 Lack of access to safe water, inadequate hygiene, and insufficient sanitation facilities accounts for nearly 88% of diarrheal cases.2 A leading cause of childhood deaths worldwide, it is responsible for approximately 1.4 million deaths each year in children.3 Thus, providing interventions to make water safe have become fundamental in reducing childhood mortality around the world.

Recent experience has shown that strategies that integrate water treatment with maternal and child health and clinic based care are particularly successful.

WaterGuard & the Safe Water System

One inexpensive household point-of-use intervention that has shown to reduce the risk of diarrhea by 25-85% is the Safe Water System (SWS).4-10 The SWS consists of three components: treatment of water using a locally produced sodium hypochlorite solution called WaterGuard, safe water storage, and improvement in hygiene and water storage through behavior change communication.4 However, ensuring sustainable water treatment and hygiene behavior change can be challenging.

Targeting Expectant Mothers — Antenatal Hygiene Kit Distribution

One effective strategy in promoting behavior change is targeting expectant mothers during pregnancy. During this period, mothers are accepting of advice from health care providers and open to hygiene promotion messages that could protect the health of their children. Even in countries with high maternal and childhood mortality, mothers report visiting an antenatal clinic at least once.11

Results from Malawi

A pilot program utilizing this approach was initiated in Malawi in two districts in 2007. As a part of this program, 15,000 pregnant women received free hygiene kits during their first antenatal clinic visit. The kit included a water storage container with a tap, a bottle of WaterGuard, and a bar of soap. Women were also eligible to receive three additional WaterGuard bottles and bars of soap during subsequent antenatal clinic visits. Evaluation of this program one year and two years later showed that integration of water treatment and handwashing products was highly effective in changing behaviors among expectant mothers. Participants had statistically significant increases in any water treatment, knowledge of WaterGuard, reported use of WaterGuard, detection of residual chlorine in stored water in the home, and purchase of WaterGuard after the depletion of their free supply. To put this into perspective, confirmed use of WaterGuard increased from 1% at baseline, to 61% at first follow-up. The water storage container provided was used in over 90% of homes, and demonstration of proper handwashing technique increased from 22% at baseline to 68% at first follow-up.12 Following a similar format, a program in Machinga District, Malawi distributed 25,000 hygiene kits in 2009 and found comparable results in water treatment, hygiene, and water storage behavior change.13

Potential for Increasing Safe Water Use in certain Demographic Groups

Perhaps the most promising finding of the pilot program evaluation was that the demographic makeup of those most impacted by the antenatal hygiene kits included groups that had been previously hard to reach through safe water promotion campaigns. Previous nationwide surveys on WaterGuard in Malawi had found that WaterGuard use tended to be highest in urban, more educated, and wealthier populations. In contrast, this study found that mothers who did not use WaterGuard at baseline but had confirmed WaterGuard use at follow-up were associated with rural residence, lower wealth, and lower education. This finding suggests this mechanism could be particularly effective in reaching rural, uneducated, and lower income populations, coincidentally the same populations that are at greatest risk of adverse outcomes from diarrheal disease.


1. WHO, http://www.who.int/water_sanitation_health/monitoring/jmpfinal.pdf. Accessed August 15, 2011.
2. (KNBS), K. N. B. o. S. and I. Macro (2010). Kenya Demographic and Health Survey 2008-09. Calverton, Maryland, KNBS and ICF Macro.
3. Boschi-Pinto C, Velebit L, Shibuya K, 2008. Estimating child mortality due to diarrhea in developing countries. Bull World Health Organ 86: 710-7.
4. Garrett V, Ogutu P, Mabonga P, Ombeki S, Mwaki A, Aluoch G, Phelan M, Quick RE, 2008. Diarrhea prevention in a high-risk rural Kenyan population through point-of-use chlorination, safe water storage, sanitation, and rainwater harvesting. Epidemiol Infect: 1-9.
5. Crump, J. A., P. O. Otieno, et al. (2005). “Household based treatment of drinking water with flocculant-disinfectant for preventing diarrhea in areas with turbid source water in rural western Kenya: cluster randomised controlled trial.” BMJ 331(7515): 478.
6. Semenza, J.C., Roberts, L., Henderson, A., Bogan, J., & Rubin, C.H. Water distribution system and diarrheal disease transmission: a case study in Uzbekistan. American Journal of Tropical Medicine & Hygiene 1998;59:941-946.
7. Quick, R.E., Venczel, L.V., Mintz, E.D., et al. Diarrhoea prevention in Bolivia through point-of use water treatment and safe storage: A promising new strategy. Epidemiology & Infection 1999; 122:83-90.
8. Quick RE, Kimura A, Thevos A, et al. Diarrhea prevention through household-level water disinfection and safe storage in Zambia. American Journal of Tropical Medicine & Hygiene 2002;66:584-589.
9. Luby, S.P., Agboatwalla, M., Hoekstra, R.M., Rahbar, M.H., Billhimer, W., & Keswick, B.H. Delayed effectiveness of home-based interventions in reducing childhood diarrhea, Karachi, Pakistan. American Journal of Tropical Medicine & Hygiene 2004;71:420-427.
10. Lule, J.R., Mermin, J., Ekwaru, J.P., et al. Effect of home-based water chlorination and safe storage on diarrhea among persons with human immunodeficiency virus in Uganda. American Journal of Tropical Medicine and Hygiene 2005;73:926-933.
11. National Statistical Office and UNICEF, 2008. Malawi Multiple Indicator Cluster Survey 2006, Final Report. Lilongwe, Malawi: National Statistical Office and UNICEF. Available at: http://www.childinfo.org/files/MICS3_Malawi_FinalReport_2006_eng.pdf. Accessed August 14, 2011.
12. Sheth AN, Russo ET, Menon M, Wannemuehler K, Weinger M, Kudzala AC, Tauzie B, Masuku HD, Msowoya TE, Quick R. Impact of the integration of water treatment and handwashing incentives with antenatal services on hygiene practices of pregnant women in Malawi. Am J Trop Med Hyg. 2010 Dec;83(6):1315-21.
13. Routh, J. Safe Water and Hygiene Promotion for Diarrheal Disease Prevention through the Government of Malawi Antenatal Care System: Machinga District. EIS conference presentation April 2011.