Of all the Millennium Development Goals, the maternal health and sanitation targets are among the farthest off track, said Rebecca Fishman, operations and special projects director of WASH Advocates. [Video Below]

An estimated 800 women die from pregnancy- or childbirth-related causes every day, and 20 times that number suffer non-lethal, but no less life-altering, complications. At the same time, 780 million people are without access to safe drinking water and 2.5 billion lack access to safe sanitation.

What is the interaction between these two trends – poor maternal health and water, sanitation, and hygiene (WASH)? And could there be ways to address both in developing countries? To commemorate International Women’s Day and World Water Day, a panel of experts gathered to discuss at the Wilson Center on March 10.

The Risk of Delivering

“The links between WASH and maternal health are quite strong,” said Fishman.

Of 54,507 health care facilities recently surveyed by the World Health Organization in 40 countries, only 46 percent had access to safe drinking water, said Merri Weinger, environmental health team leader of the Maternal Child Health Division of USAID’s Bureau for Global Health. A study conducted in Tanzania found only 44 percent of health facilities that delivered women were water and sanitation safe and the number was even lower when considering the actual delivery room – 24 percent – said Lenka Benova, research fellow at the London School of Hygiene and Tropical Medicine.

This, unsurprisingly, affects mother and child health in major ways. According to a meta-analysis of three studies conducted by Benova and two other authors, women living in poor sanitation environments are three times as likely to die from maternal health-related issues compared to women who do not, while women living under poor water conditions have a maternal mortality ratio 50 percent higher than those that do not. Half the malnutrition cases worldwide can be attributed to poor water, sanitation, and hygiene, said Annie Toro, senior adviser to International Medical Corps.

Poor WASH also undermines efforts by governments and NGOs to get more women to deliver with skilled attendants. When conditions are so bad, “we have to be careful…when we push women to deliver in health care facilities,” said Benova. “What is the actual environment that they are delivering in?”

This feedback loop tends to affect the poor and marginalized the most, contributing to stubborn levels of inequality. “Women that are least likely to have a safe water and sanitation environment at home are also the most likely to deliver [in places without safe water and sanitation],” said Benova. “Women who have a better water and sanitation environment can actually afford to give birth in a [better] facility.”

Empowering Women and the Community

The African Medical and Research Foundation (AMREF) is the largest non-governmental health development organization based in Africa and has made a concerted effort to integrate WASH and maternal health interventions, said Lisa Meadowcroft, executive director of AMREF USA.

Improved access has been a particular focus. Women in sub-Saharan Africa spend an estimated 40 billion hours a year collecting and carrying water, many of them while pregnant. The time spent collecting water not only affects health, but also impedes women and girls’ personal development, Meadowcroft said; they don’t have time to start businesses, they can’t go to school, and they are often vulnerable to assault coming to and from water sources. “We recognize that women and children are the most vulnerable population in societies and we also recognize that often it is women who are the agents of change in their community and in their family,” she said.

In Kenya, AMREF taught women how to build improved and reliable wells, which not only enhanced health and sanitation and reduced the amount of time it took to collect water, but improved food security and reduced poverty. The women who received the training developed a business and have started installing wells in nearby communities for a fee. “On any given day the poverty level is such that you earn about a dollar and a quarter; these women are earning $100 a month from doing this,” said Meadowcroft.

In the Kitui West and Mutito communities, AMREF undertook efforts to improve WASH at five local health facilities, building a water tank and latrines, adding hand-washing stations, and working with the government health teams to try to ensure more reliable staffing. 

USAID Efforts

USAID integrates WASH into their maternal health programming in several ways, said Weinger.

The agency’s Water and Development Strategy, introduced for the first time last year, has the goal of improving water supplies for an additional 10 million people around the world, improving sanitation for 6 million, and improving key hygiene behaviors in 30 priority countries. Weinger said missions have been required to “add sanitation as a key element of their water, health, and nutrition activities.”

Weinger explained one example of WASH integration with maternal health via a program in Malawi. In 2007, USAID started collaboration with the Centers for Diseases Control and Prevention, UNICEF, Population Services International, and the Malawi government on an antenatal care program. The partnership targeted health clinics with training on water treatment and hand-washing as well as water hygiene kits. “We…wanted to increase the attendance at antenatal and postnatal care visits, as well as women going to facilities to deliver their children,” said Weinger, and a follow-up evaluation in 2010 showed promising results with increased numbers of antenatal care visits and increased numbers of deliveries in facilities.

USAID is also collaborating with the World Health Organization and UNICEF “to produce a joint document this year on the how-to’s of integrating WASH and nutrition,” said Weinger. “The nutritional status of a pregnant woman is a critical determinant of maternal and neonatal survival,” as it ensures mothers are well nourished and prevents diarrhea, intestinal worms, and environmental enteropathy, which is caused by fecal-oral contamination.

WASH for the Future

“Investing in the health of women and girls around the globe is one of the most effective, yet under-utilized, tools for encouraging social stability and economic prosperity in the developing world,” said Toro, quoting U.S. Senator Jeanne Shaheen (New Hampshire). Investments in universal access to WASH are estimated to save over $134 billion in annual health costs, lost productivity, and reduced mortality, she said.

To ensure that WASH gets more traction and integration, it should be included as a priority in the post -Millennium Development Goals agenda, said Toro. “Quality and equity of care is a priority across all post-2015 health goals, but especially for maternal health where poverty, poor infrastructure, and gender norms can prevent women from seeking care.” She also recommended support for a number of pieces of U.S. legislation, including H. Res. 135, which recognizes the importance of frontline global health workers; the Senator Paul Simon Water for the World Act, H.R. 2901; and increased topline appropriations for the Senator Paul Simon Water for the Poor Act of 2005.

Weinger suggested keeping the pressure on developing country governments to improve WASH conditions in health care facilities – the agenda must be included in national budgets as part of the service delivery, she said. The World Health Organization, UNICEF, Joint Monitoring Program, and UN Water have all made proposals for global monitoring of WASH in health care facilities and schools for the first time, along with universal WASH coverage in health care facilities by 2030.

The successful integration of WASH programs in some developing countries demonstrates the ability to significantly improve maternal health through partnerships with advocacy agencies, communities, and the government – but also the imperative to spread the approach elsewhere. “Water, sanitation, and maternal health must be inextricably linked,” said Benova.

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