From the rising to the setting of the sun in a Ugandan village, the rural Ugandan mother’s life is impacted by water. She wakes up thinking about fetching water from the nearest borehole, and goes to bed at night hoping she has the jerry cans filled with enough of this precious substance.
Walking on average 48 minutes to fetch and return with water,1 a young girl named Prossy walks toward a water borehole. She fills her jerry cans and races back home. She needs to get to school by 7:30a.m.—it is now 6:45, and the sun is just rising. Her bright future rests significantly on her ability to complete her education—to finish at least primary school, and hopefully secondary. Poorly-educated mothers have higher rates of maternal death, and are less likely to plan for their families, both in terms of total number of children, and the spacing of their births.2 Both of these factors (high fertility and short spacing between births) are significant risk factors for maternal and newborn death.3
This morning, Prossy is fortunate to have escaped any predators—both man and beast—that lie in wait for young girls who are searching for the life-sustaining commodity. Her older sister Lydia was not so fortunate last year, and now she has a baby in her arms. The accused of the crime takes no responsibility, and Lydia has joined the ranks of the school dropouts. She has no chance of finishing her education, unless her school director breaks the unwritten rule of prohibiting young mothers from rejoining school after giving birth. There are no social supports or special programs to reintegrate these young mothers back into educational fora. Instead, they are often denied entrance into any school. Even if readmitted, there are certainly no facilities within the schools for breast feeding or supporting the care of a newborn.4
Lydia is quickly married off to an older man who wants a second wife. She will be pregnant again next year, as the husband will most certainly want another child of his own with her. And so, the circle of poverty has begun at a young age for the adolescent mother. Her risk of dying from a pregnancy-related complication will continue to rise with each pregnancy, as she has little access to family planning or the negotiating skills to limit the number of children she bears for the husband who “rescued” her from being a single mother.
Although Prossy and Lydia’s individual stories are fictitious, they are repeated several thousand times in rural Uganda. It all boils down to water, its availability, and its role in the lives of millions of women and girls in East Africa.
Each year, 289,000 women die during pregnancy and child birth. Many more suffer from severe birth injuries, such as obstetric fistula, with the highest numbers in developing countries, and particularly in sub-Saharan Africa.5
Children under five whose mothers die during the process of pregnancy and childbirth are more likely to lose their lives before their fifth birthday.6
The reasons behind this tragedy have been well studied and documented by many bodies including the World Health Organization (WHO). The highlighted three delays that lead to maternal (and newborn) deaths are: in seeking health care; en route to hospital; and in receiving lifesaving care once at the health facilities.7 The actual medical causes of death are hemorrhage (excessive bleeding), sepsis (infection), obstructed labor, complications of abortion, and hypertensive (high blood pressure) disorders.8 Multidisciplinary approaches have been highlighted as a key strategy to reducing these avoidable deaths.9
The Cycle of Life and Reproduction
Water touches every component of human life. That is no surprise, as 78 percent of a newborn’s weight is composed of water.10 In adults, water is still the most significant component (60 percent) of the human body. Water plays a role in each part of the cycle of life. The presence, or absence, of water at each stage of life can have impacts that last a lifetime—from before the embryo is conceived, to the earliest days of an infant drinking water by themself or their mother sipping her afternoon tea, the theme and footprint of water runs throughout.
Before the Cycle of Life Begins: Pre-pregnancy
The factors and issues around the provision of water for girls and women can be thought of as the “preconceptual components” in the intersection between water and safe motherhood. Before a female is even pregnant, water plays a role in potentially increasing her risks of childbearing. The risk of adolescent pregnancy due to rape (or ‘defilement,’ as it is called in East Africa) while girls are fetching water, the inadequate physical development of young women due to malnutrition (caused by unsafe water, and subsequent chronic diarrhea and malabsorption), and the lack of access to safe and readily available sources of water contributes to deaths of young mothers who are pregnant far too young. This impact of water is realized early in the cycle of motherhood. Yet, water continues to spill over into other factors contributing to the health and safety of mothers and newborns.
Early Days of the Cycle
The availability of safe and clean water, though rarely discussed, is actually pivotal in appreciating the complex factors surrounding not only the causes of unsafe motherhood, but the solutions to this ongoing human tragedy. Take the example of maternal deaths due to complications of abortion. In the developing world, young girls like Lydia can be exposed to the risks of unwanted pregnancy, which can follow rape (for example, while collecting water) or coercion in return for small favors. These young girls will resort to crude means to try and terminate the unwanted pregnancy, often using local herbs or the help of non-skilled and low-level health workers. Often, these young women will then present in the health facilities in critical condition, with either excessive bleeding or overwhelming infection. How can one imagine a hospital managing either of those complications in the absence of clean, safe water? Yet this is the reality in many remote facilities that are dependent upon rainwater harvesting, and so are inevitably without water during the dry season.
Highest Risk: Delivery
The cycle continues for the pregnant mother: after nine long months of nourishing her soon-to-be child, water continues to be of paramount importance to the mother and her infant. The safety and availability of clean and safe water during the actual delivery are essential for mothers and their newborns. International organizations such as WHO stipulate basic requirements for the care of critical complications of pregnancy. These are essential functions or services (e.g., provision of emergency caesarean section, medications like oxytocin to stop bleeding, etc.) that should be available for all pregnant mothers—yet these requirements do not include safe and clean water. It is assumed that water will be available, but in many places, it is not. A mother who receives antibiotics (one of the basic requirements stipulated by the WHO) for a postpartum infection, but has no access to safe water, will undoubtedly become ill again, or simply contract another kind of infection.11 Antibiotic resistance increases with use of antibiotics, even in resource-poor settings, and the situation becomes even more complicated than previously imagined.12
Women who deliver in unsanitary conditions lacking clean water are exposed to significant risk. Labor and delivery is a very vulnerable time, with body fluids being exchanged between mother and baby, as well as the risk of contamination of the health worker by the mother, and also to the mother if the worker’s hands and instruments have not been cleaned with safe water.
During the process of labor and child birth, water is essential. Many times, the pregnant mother can only rely on the system which is already in place. During labor, there is little she can do if clean water is not readily available. This is the unacceptable reality for some maternity centers and hospitals in low- and middle-income countries. It is not simply inconvenient that water is not readily available, but rather, it compounds the high risk of dying from the top two major causes of maternal deaths: haemorrhage, and infection.
Serious infections can develop due to bacteria that the mother acquires during delivery as a result of unclean hands or instruments. These include significant and deadly agents such as tetanus, which can kill both the mother and baby if they have no immunity to the disease. Approximately 15 percent of all maternal deaths occur as a result of infection. But, in addition to death, many mothers have long-term complications including chronic pelvic pain (due to pelvic infection), and infertility as a result of infections caused by poor or inadequate hygiene.13
Addressing this very obvious gap of water and sanitation in hospitals has been a key strategy of Save the Mothers’ Mother Baby Friendly Hospital program—a 10-step initiative to improve quality of care for mothers and newborns.14 But, quality of care goes far beyond the skills of medical personnel, nurses, and doctors—these skilled people can never give quality care without clean water. This is water for both their clients and for themselves (e.g., to clean off their own skin from potential infectious fluids, such as splashed blood), or to sip a cool glass of water after eight hours of steady work in an environment where one cannot leave mothers and newborn babies unattended in order to search for water to drink. The lack of water in these facilities robs patients, and, indeed, their health workers, of dignity and safety.
The End of the Cycle: Post-delivery
Like mother, like child: newborn health shares a similar outcome when it comes to the impact of the glaring gap caused by the lack of clean water, and its consequences to the health of mothers. Once delivered, the baby, whose mother has no access to clean and safe water, is immediately exposed to bacteria and parasites to which it has little or no immunity. The mother who delivers her newborn, relieves herself at the hospital’s pit latrine, and then returns to breastfeed her baby on the ward without washing her hands (as no water is available), may soon discover that her newborn has developed sepsis, a generalized blood infection.
Her baby will only survive if it is one of the fortunate ones- unlike the 680,000 other newborns that die in the first week of life.15 Worldwide, 2.9 million babies die within the first week of life. Infection is the leading cause of death among this most vulnerable population, and unwashed maternal hands are a major contributor to these deadly infections.16
The priority to ensure that health facilities have access to safe water cannot be understated. As we encourage mothers to deliver in settings where they can be assured of life-saving interventions (e.g., antibiotics and medications to prevent haemorrhage, etc.), provision for safe water and sanitation must be part of the package. Otherwise, mothers and newborns will die from the microscopic consequences (i.e., bacteria) of unsafe motherhood.
Solutions for Safe Water in Maternal and Newborn Health
Solutions to ensure that young girls and women have access to water during their childhood and early pregnancy are beyond the scope of this article. But, for a moment, we will focus on the critical few hours that pertain to reproductive health: the delivery of a baby. The provision of safe, clean, and accessible water for mothers and their newborns is essential if maternal/neonatal health is to improve among some of the world’s most vulnerable women and babies. Depending on the amount required, the location of the health facility, and other environmental factors, the investment can be significant. However, creative and sustainable technologies can reduce costs and minimize long term expenditures.
The introduction of solar-powered pumps to ensure a steady supply of water to a large local hospital in Uganda, through the Canadian-based non-governmental organization H2O 4 All, has ensured that water is available for the care of mothers and their babies.17 With the addition of a water purification system, there is also safe drinking water for both staff and patients. The change in morale and motivation among health workers as a result of this intervention is palpable. It also serves as an example of an effective partnership, where experts in water technology (H2O 4 All) have worked in tandem with technical experts in maternal health (Save the Mothers) as partners through the Mother Baby Friendly Hospital program to ensure that mothers and their babies have a safe and dignified delivery. Silo initiatives that do not address the complete health package required for safe motherhood will have a limited impact on reducing maternal/newborn deaths.
In addition, creative ideas to improve water and sanitation are being piloted and introduced to some of the world’s most vulnerable women through organizations like Wish for WASH, a social impact organization seeking to bring innovation to sanitation through culturally-specific research, design, and education. Wish for WASH has introduced the SafiChoo toilet, which, through lean manufacturing, customer discovery, and empathic design, offers a “toolbox of options,” allowing the user to choose how to go to the bathroom to best meet their needs.18
The deaths of 680,000 newborns in Sub-Saharan Africa, South Asia, and Latin America due to infection could be minimized by two simple interventions, both of which are known, yet remain challenging to implement: improved maternal vaccinations (especially tetanus) and improved hygiene. Randomized, controlled trials in Pakistan, Nepal, and Bangladesh have previously demonstrated that clean delivery with chlorhexidine cord-cleansing at and after delivery reduces neonatal death.19-21
The research and innovations are in place to ensure that mothers and their newborns everywhere can drink, wash, and clean in safe and accessible water. It is not a privilege, but a basic human right. Health workers will also suffer less illness and risk when the tap is turned on. The challenge now remains to introduce the resources and the determination to ensure that every mother and her baby have access to this simple, lifesaving intervention: safe and clean water.
- Pickering, AJ & Davis, J. Freshwater Availability and Water Fetching Distance Affect Child Health in Sub-Saharan Africa. Environmental Science Technology 46(4): 2391–2397 (2012).
- Kaggwa, EB, Diop, N & Storey, JD. The role of individual and community normative factors: A multilevel analysis of contraceptive use among women in union in Mali. International Family Planning Perspectives 34: 79-88 (2008).
- Safe Motherhood Action Agenda: Priorities for the Next Decade. Report on Safe Motherhood Technical Consultation October 18-23, 1997 (Family Care International, Colombo, Sri Lanka, 1997).
- Hindin, MJ & Fatusi, AO. Adolescent Sexual and Reproductive Health in Developing Countries: An Overview of Trends and Interventions. International Perspectives on Sexual and Reproductive Health 35: 58-62 (2009).
- Trends in Maternal Mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, the World Bank and the United Nations Population Division [online] (2014). http://www.unfpa.org/publications/trends-maternal-mortality-1990-2013#sthash.luiCHVbZ.dpuf.
- Maternal Mortality Fact Sheet. World Health Organization [online] (2015). http://www.who.int/mediacentre/factsheets/fs348/en/.
- Thaddeus, S & Maine, D. Too Far to Walk: Maternal Mortality in Context. Social Science and Medicine 38:1091-1110 (1994).
- Khan, K, Wojdyla, D, Say, L, Gulmezoglu, M & Van Look, P. WHO Analysis of causes of maternal death: a systematic review. The Lancet 367: 1066-1074 (2006).
- Chamberlain, J & Watt, S. Education for safe motherhood: a Save the Mothers advocacy initiative. Leadership in Health Services 21: 278-289 (2008).
- The Water in You. USGS Water Science School [online] (2016). http://water.usgs.gov/edu/propertyyou.html.
- Monitoring emergency obstetric care: a handbook (World Health Organization, Geneva, 2009).
- Aiken, AM et al. Risk and causes of paediatric hospital-acquired bacteraemia in Kilifi District Hospital, Kenya: a prospective cohort study. The Lancet 378: 2021–27 (2011).
- Education material for teachers of midwifery. Midwifery education modules. Second Edition (World Health Organization, Geneva, 2008).
- Chamberlain, J & Nakabembe, E. Moving Goals and Policy into Effective Action for Mothers and Newborns Around the World: the Mother Baby Friendly Hospital Initiative. Journal of Obstetrics and Gynaecology Canada 14 (2015).
- Seale, AC et al. Estimates of possible severe bacterial infection in neonates in sub-Saharan Africa, south Asia, and Latin America for 2012: a systematic review and meta-analysis. Lancet Infectious Diseases 14: 731–41 (2014).
- Bhutta, ZA et al. What works? Interventions for maternal and child undernutrition and survival. The Lancet Group Series 371, 2–8: 417–440 (2008).
- H2O 4 All [online] (2016). http://h2o4all.org/.
- Wish for Wash [online] (2016). http://www.wishforwash.com/#product.
- Mullany, LC et al. Topical applications of chlorhexidine to the umbilical cord for prevention of omphalitis and neonatal mortality in southern Nepal: a community-based, cluster-randomised trial. The Lancet 367: 910–18, (2006).
- Arifeen, SE et al. The effect of cord cleansing with chlorhexidine on neonatal mortality in rural Bangladesh: a community-based, cluster-randomised trial. Lancet 379: 1022–28 (2012).
- Soofi, S et al. Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community-based, cluster-randomised trial. The Lancet 379: 1029–36, (2012).