Neiwa
JF-Expert Member
- Feb 17, 2012
- 728
- 633
Abstract
Background
Inadequate water and sanitation during childbirth are likely to lead to poor maternal and newborn outcomes. This paper uses existing data sources to assess the water and sanitation (WATSAN) environment surrounding births in Tanzania in order to interrogate whether such estimates could be useful for guiding research, policy and monitoring initiatives. Methods
We used the most recent Tanzania Demographic and Health Survey (DHS) to characterise the delivery location of births occurring between 2005 and 2010. Births occurring in domestic environments were characterised as WATSAN-safe if the home fulfilled international definitions of improved water and improved sanitation access. We used the 2006 Service Provision Assessment survey to characterise the WATSAN environment of facilities that conduct deliveries. We combined estimates from both surveys to describe the proportion of all births occurring in WATSAN-safe environments and conducted an equity analysis based on DHS wealth quintiles and eight geographic zones.
Results
42.9% (95% confidence interval: 41.6%–44.2%) of all births occurred in the woman's home. Among these, only 1.5% (95% confidence interval: 1.2%–2.0%) were estimated to have taken place in WATSAN-safe conditions. 74% of all health facilities conducted deliveries. Among these, only 44% of facilities overall and 24% of facility delivery rooms were WATSAN-safe. Combining the estimates, we showed that 30.5% of all births in Tanzania took place in a WATSAN-safe environment (range of uncertainty 25%–42%). Large wealth-based inequalities existed in the proportion of births occurring in domestic environments based on wealth quintile and geographical zone.
Conclusion
Existing data sources can be useful in national monitoring and prioritisation of interventions to improve poor WATSAN environments during childbirth. However, a better conceptual understanding of potentially harmful exposures and better data are needed in order to devise and apply more empirical definitions of WATSAN-safe environments, both at home and in facilities.
Introduction
At the end of the 18[SUP]th[/SUP] century, the causal link between poor-hand hygiene and puerperal sepsis was recognised, eventually enabling reductions in maternal deaths [1]–[3]. Currently, WHO guidelines for delivery in health facilities advise frequent hand-washing, and clean birth kits have been designed for births in domestic environments [4]. A recent systematic review concluded that a lack of sanitation facilities appears to be associated with maternal mortality, as does lack of water access [5]. This review highlighted the paucity of primary studies assessing the impact of water and sanitation environments on maternal mortality and recommended future assessments of the burden of exposure to poor water and sanitation during pregnancy and delivery.
The United Republic of Tanzania is a sub-Saharan African country with 45 million inhabitants. Despite a 3.5% average annual rate of reduction in maternal mortality between 1990 and 2013, the current maternal mortality ratio of 454 deaths per 100,000 births in 2010 means that Tanzania remains off-track to achieve the Millennium Development Goal 5 target to reduce the maternal mortality ratio by three quarters between 1990 and 2015 [6]–[8]. Approximately 7,900 women die annually from the largely preventable or treatable complications of pregnancy and childbirth; and sepsis is estimated to account for 9% of these deaths [9].
Globally, an effective intrapartum care strategy, encompassing institutional delivery with referral capacities, has been suggested as a strategy to reduce maternal mortality [10]. Tanzania has seen a modest increase in the proportion of births occurring in health facilities; from 43.5% in 1999 to 50.1% in 2010 [7], but wide socio-economic inequalities in the utilization of skilled birth attendance exist [11]. To reduce maternal mortality, the Tanzanian government proposed scaling-up the availability of basic emergency obstetric and newborn care services at dispensaries and health centres, and improving the ability of rural health centres to perform caesarean sections and blood transfusions [6]. The health service delivery system in Tanzania is characterized as a network of hospitals, health centres and dispensaries (primary care clinics) [12].
In 2010, the proportion of Tanzanian population with access to improved water sources was 53%, a slight decrease from 55% in 1990. Access to improved sanitation was very low at 10% in 2010, a marginal improvement from 7% in 1990 [13]. A survey of 175 public facilities providing maternal care in Southern Tanzania showed only 83% of dispensaries had staff hand-washing facilities. The study did not report on other aspects of water, sanitation and hygiene environment, such as the availability of soap, running water, or hygiene practices among health staff and patients [14]. However, a recent study in Tanzania found that women who rated their local primary care centres as poor quality were more likely to bypass them to deliver in hospitals; upgrading or renovating the clinics reduced bypassing by 60% [15].
The main objective of this paper is to estimate the coverage of water and sanitation (WATSAN) in the various birth environments. We propose using household data to describe the WATSAN environment of home birth settings, and facility surveys to describe the WATSAN environment of facility deliveries. We selected Tanzania for this case study because both types of surveys were available and relatively recent. The secondary objective of this country study is to demonstrate how existing secondary data can create generate useful information for policy initiatives and future primary research. This approach permits an assessment of geographical variability in the coverage of WATSAN in birth environments that may generate useful information for prioritisation and targeting of limited resources.
Methods
Data sources
The Demographic and Health Surveys (DHS) are cross-sectional nationally representative household surveys, conducted in over 90 countries worldwide. The Service Provision Assessments (SPA) are cross-sectional nationally representative facility surveys conducted by the same group, in 15 countries. We used the most recent Tanzania DHS (DHS, 2010), which reported on the number and location of live births occurring between 2005–2010 to women in sampled households [7]. The DHS dataset included a relative socio-economic categorisation of women's households, wealth quintile [16], and information on household water and sanitation.
We used the most recent SPA survey conducted in 2006 to characterise the WATSAN environment of facilities. This survey included a nationally-representative sample of 611 public and non-public facilities [17]. A questionnaire was administered and elements of the delivery room environment were observed during facility visits. The analysis in this paper was limited to those health facilities which reported conducting deliveries. Both DHS and SPA surveys were representative nationally and on the level of eight geographic zones (Central, Western, Lake, Southern Highlands, Southern, Northern, Zanzibar and Eastern).
Definitions
Birth location.
We characterised births reported in the DHS by delivery location. Births outside of a health facility were classified as having occurred in the woman's home or in a different location (e.g., parental or traditional birth attendant's home). The duration of residence in the current dwelling was not collected and we were unable to distinguish home births that occurred in the current residence from those in a previous residence. Therefore, all births reported in the woman's home were assumed to have occurred in the current household environment (the dwelling assessed by the household questionnaire). Births which were delivered in health facilities were characterised according to the level of health facility reported (dispensary, health centre or hospital). Births that did not occur in the woman's home or in a health facility were described as having occurred in ‘other locations'.
Domestic WATSAN environment.
We defined the home birth environment as WATSAN-safe if both the drinking water source and the sanitation facility access could be characterised as ‘improved' according to the WHO/UNICEF Joint Monitoring Programme (JMP) definition (Table 1) [18]. A WATSAN-unsafe environment, on the other hand, described homes in which either water or sanitation, or both were classified as ‘unimproved'. This construct does not capture many other important components of the environment, such as water quality, consistency of availability, actual use of sanitation facilities or hygienic practices, but it does indicate the existence and location of physical assets required for hygienic behaviour during childbirth and the postpartum period.
Read the rest of the Paper On Methods, Results, Discussion and Figures via - http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0106738
Background
Inadequate water and sanitation during childbirth are likely to lead to poor maternal and newborn outcomes. This paper uses existing data sources to assess the water and sanitation (WATSAN) environment surrounding births in Tanzania in order to interrogate whether such estimates could be useful for guiding research, policy and monitoring initiatives. Methods
We used the most recent Tanzania Demographic and Health Survey (DHS) to characterise the delivery location of births occurring between 2005 and 2010. Births occurring in domestic environments were characterised as WATSAN-safe if the home fulfilled international definitions of improved water and improved sanitation access. We used the 2006 Service Provision Assessment survey to characterise the WATSAN environment of facilities that conduct deliveries. We combined estimates from both surveys to describe the proportion of all births occurring in WATSAN-safe environments and conducted an equity analysis based on DHS wealth quintiles and eight geographic zones.
Results
42.9% (95% confidence interval: 41.6%–44.2%) of all births occurred in the woman's home. Among these, only 1.5% (95% confidence interval: 1.2%–2.0%) were estimated to have taken place in WATSAN-safe conditions. 74% of all health facilities conducted deliveries. Among these, only 44% of facilities overall and 24% of facility delivery rooms were WATSAN-safe. Combining the estimates, we showed that 30.5% of all births in Tanzania took place in a WATSAN-safe environment (range of uncertainty 25%–42%). Large wealth-based inequalities existed in the proportion of births occurring in domestic environments based on wealth quintile and geographical zone.
Conclusion
Existing data sources can be useful in national monitoring and prioritisation of interventions to improve poor WATSAN environments during childbirth. However, a better conceptual understanding of potentially harmful exposures and better data are needed in order to devise and apply more empirical definitions of WATSAN-safe environments, both at home and in facilities.
Introduction
At the end of the 18[SUP]th[/SUP] century, the causal link between poor-hand hygiene and puerperal sepsis was recognised, eventually enabling reductions in maternal deaths [1]–[3]. Currently, WHO guidelines for delivery in health facilities advise frequent hand-washing, and clean birth kits have been designed for births in domestic environments [4]. A recent systematic review concluded that a lack of sanitation facilities appears to be associated with maternal mortality, as does lack of water access [5]. This review highlighted the paucity of primary studies assessing the impact of water and sanitation environments on maternal mortality and recommended future assessments of the burden of exposure to poor water and sanitation during pregnancy and delivery.
The United Republic of Tanzania is a sub-Saharan African country with 45 million inhabitants. Despite a 3.5% average annual rate of reduction in maternal mortality between 1990 and 2013, the current maternal mortality ratio of 454 deaths per 100,000 births in 2010 means that Tanzania remains off-track to achieve the Millennium Development Goal 5 target to reduce the maternal mortality ratio by three quarters between 1990 and 2015 [6]–[8]. Approximately 7,900 women die annually from the largely preventable or treatable complications of pregnancy and childbirth; and sepsis is estimated to account for 9% of these deaths [9].
Globally, an effective intrapartum care strategy, encompassing institutional delivery with referral capacities, has been suggested as a strategy to reduce maternal mortality [10]. Tanzania has seen a modest increase in the proportion of births occurring in health facilities; from 43.5% in 1999 to 50.1% in 2010 [7], but wide socio-economic inequalities in the utilization of skilled birth attendance exist [11]. To reduce maternal mortality, the Tanzanian government proposed scaling-up the availability of basic emergency obstetric and newborn care services at dispensaries and health centres, and improving the ability of rural health centres to perform caesarean sections and blood transfusions [6]. The health service delivery system in Tanzania is characterized as a network of hospitals, health centres and dispensaries (primary care clinics) [12].
In 2010, the proportion of Tanzanian population with access to improved water sources was 53%, a slight decrease from 55% in 1990. Access to improved sanitation was very low at 10% in 2010, a marginal improvement from 7% in 1990 [13]. A survey of 175 public facilities providing maternal care in Southern Tanzania showed only 83% of dispensaries had staff hand-washing facilities. The study did not report on other aspects of water, sanitation and hygiene environment, such as the availability of soap, running water, or hygiene practices among health staff and patients [14]. However, a recent study in Tanzania found that women who rated their local primary care centres as poor quality were more likely to bypass them to deliver in hospitals; upgrading or renovating the clinics reduced bypassing by 60% [15].
The main objective of this paper is to estimate the coverage of water and sanitation (WATSAN) in the various birth environments. We propose using household data to describe the WATSAN environment of home birth settings, and facility surveys to describe the WATSAN environment of facility deliveries. We selected Tanzania for this case study because both types of surveys were available and relatively recent. The secondary objective of this country study is to demonstrate how existing secondary data can create generate useful information for policy initiatives and future primary research. This approach permits an assessment of geographical variability in the coverage of WATSAN in birth environments that may generate useful information for prioritisation and targeting of limited resources.
Methods
Data sources
The Demographic and Health Surveys (DHS) are cross-sectional nationally representative household surveys, conducted in over 90 countries worldwide. The Service Provision Assessments (SPA) are cross-sectional nationally representative facility surveys conducted by the same group, in 15 countries. We used the most recent Tanzania DHS (DHS, 2010), which reported on the number and location of live births occurring between 2005–2010 to women in sampled households [7]. The DHS dataset included a relative socio-economic categorisation of women's households, wealth quintile [16], and information on household water and sanitation.
We used the most recent SPA survey conducted in 2006 to characterise the WATSAN environment of facilities. This survey included a nationally-representative sample of 611 public and non-public facilities [17]. A questionnaire was administered and elements of the delivery room environment were observed during facility visits. The analysis in this paper was limited to those health facilities which reported conducting deliveries. Both DHS and SPA surveys were representative nationally and on the level of eight geographic zones (Central, Western, Lake, Southern Highlands, Southern, Northern, Zanzibar and Eastern).
Definitions
Birth location.
We characterised births reported in the DHS by delivery location. Births outside of a health facility were classified as having occurred in the woman's home or in a different location (e.g., parental or traditional birth attendant's home). The duration of residence in the current dwelling was not collected and we were unable to distinguish home births that occurred in the current residence from those in a previous residence. Therefore, all births reported in the woman's home were assumed to have occurred in the current household environment (the dwelling assessed by the household questionnaire). Births which were delivered in health facilities were characterised according to the level of health facility reported (dispensary, health centre or hospital). Births that did not occur in the woman's home or in a health facility were described as having occurred in ‘other locations'.
Domestic WATSAN environment.
We defined the home birth environment as WATSAN-safe if both the drinking water source and the sanitation facility access could be characterised as ‘improved' according to the WHO/UNICEF Joint Monitoring Programme (JMP) definition (Table 1) [18]. A WATSAN-unsafe environment, on the other hand, described homes in which either water or sanitation, or both were classified as ‘unimproved'. This construct does not capture many other important components of the environment, such as water quality, consistency of availability, actual use of sanitation facilities or hygienic practices, but it does indicate the existence and location of physical assets required for hygienic behaviour during childbirth and the postpartum period.
Read the rest of the Paper On Methods, Results, Discussion and Figures via - http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0106738