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National Institute of Environmental Health Sciences

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Poor Sanitation Linked to Adverse Pregnancy Outcomes in India

By Tara Failey

Young mother holdeing her child in India

A new mother in India
(Photo courtesy of University of Nebraska)

A unique study found that sanitation practices such as open defecation are associated with elevated risk of adverse birth outcomes in rural India. The study, recently published in PLOS Medicine, provides insight on how pregnancy outcomes compare for women who use a latrine verses those who defecate in the open.

Findings from the study show that pregnant women who defecate in the open have a significantly greater risk of preterm birth, but not low birth weight. "Our results show that sanitation is an important dimension of maternal and child health, but it’s distinct from social class and caste," says Pinaki Panigrahi, M.D., Ph.D., senior paper author and professor of epidemiology and pediatrics at the University of Nebraska Medical Center College of Public Health. “These finding may be against conventional wisdom — it’s often thought that, if you are poor, you are more likely to have a poor pregnancy outcome, since income is often tied to other poor health indices.”

Historically, research on poor water, sanitation, and hygiene (WASH) practices, which includes the impact of open defecation, has focused on infectious diseases or a direct illness, but rarely have birth outcomes been studied directly. This study is among the first to link WASH impacts to non-infectious adverse birth outcomes.

In conducting this study, the researchers enrolled 670 women during their first trimester of pregnancy, recorded information about toilet access and sanitation practices for each woman, and followed them until their child’s birth. The team observed that nearly two-thirds of the women practiced open defecation, while a quarter experienced an adverse pregnancy outcome, defined in this study as preterm birth, low birth weight, spontaneous abortion, or stillbirth.

Need for Improved Water, Sanitation, and Hygiene in India

Boy playing in road of polluted sewers
Open sewers used for defecation and trash dumping contribute to unsafe environments in India (Photo courtesy Wikimedia)

Open defecation as well as other poor WASH practices can lead to adverse pregnancy outcomes for several reasons. First, poor sanitation can promote hookworm infection, causing maternal anemia, which is linked to preterm births and low birth weight. Second, exposure to human feces containing infectious organisms during pregnancy may increase the risk of disease and infection, complicating pregnancy.

“For much of the world, the importance of WASH became apparent in the early to mid-1800s around the time of the industrial revolution,” says Panigrahi. “As sanitation and water quality improved, there was a simultaneous improvement in public health, reducing infectious diseases like cholera and typhoid. However, in the developing world, many countries have overlooked the need for improved WASH.” The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation estimates that 946 million people practice open defecation, with the highest rates remaining in Asia and sub-Saharan Africa. In India, more than 44 percent of the population practices open defecation.

Panigrahi says that poor hygiene standards tend to cross social class. Further, he notes a stark contrast between technological advancement and basic sanitation: Many homes in India may have televisions and cell phones, but lack latrines and basic sanitation.

In India’s Odisha state, where this study took place, only 18.2 percent of households have access to improved sanitation, while 75 percent of households practice open defecation. These poor sanitation practices are coupled with a high infant death rate of 57 deaths per 1,000 live births. “To improve birth outcomes in this region, our study shows there’s a need to improve sanitation and stop open defecation, while also conducting follow-up studies to assess other steps we should take,” says Panigrahi.

Future Research and Vision

During the next stages of their research, the team seeks to further examine the biological basis of these observations. For instance, what processes does open defecation cause or induce in pregnant women and when? And how might the identified processes be stopped or minimized? The team also seeks to explore other factors, such as diet, use of biomass burning cook stoves, and other socio-cultural factors, which may contribute to adverse pregnancy outcomes. “We live in a complex world, and understanding the full picture of what’s causing poor birth outcomes requires asking more questions,” says Panigrahi.

Pinaki Panigrahi, M.D., Ph.D.

University of Nebraska researcher Pinaki Panigrahi, M.D., Ph.D.
(Photo courtesy of University of Nebraska)

Further, the research team aims to educate pregnant women in India about the risks of poor sanitation and approaches to avoid those risks. Although the study found that adverse birth outcomes were independent of poverty level, education levels were found to be associated with improved sanitation practices and lower risk of adverse birth outcomes. To act on these findings, Panigrahi says, “It’s important to be strategic about how we integrate educational approaches into our interventions for pregnant women.” He says educating pregnant women can improve knowledge about safe hygiene practices and good hygiene behavior, and improve birth outcomes.

Ultimately, Panigrahi aims to create an improved environment to support better pregnancy outcomes to improve the next generation. Since low-birthweight babies have a higher future risk of diabetes and hypertension, improving birth outcomes in developing countries will not only improve maternal and child health, but also minimize the burden of future chronic diseases.

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