Home > Soapbox Updates > Measuring WASH in Maternity Units

In 2015, WHO and UNICEF reported on the status of WASH (water, sanitation and hygiene) in healthcare facilities (HCFs) in 54 low- and middle-income countries (LMICs). They found that 38% of HCFs do not provide users access to an improved water source, 19% do not provide improved sanitation, and 35% do not have soap for handwashing.

Without WASH, it is impossible to provide quality care, prevent healthcare-associated infections (HAI) and reduce the spread of antimicrobial resistance.

WASH provides an enabling environment for healthcare workers to perform care using infection prevention and control (IPC) best practices. Provision of WASH in healthcare facilities is fundamental for respecting the dignity and rights of all those who seek care as well as healthcare staff.

Why is WASH in maternity units so important?

Sepsis is a leading cause of maternal and newborn death, making up between 4 and 56% of all causes of death among hospital born babies1. The contribution to these deaths from HAIs is estimated to be significant2.

The disease burden associated with inadequate WASH provision goes beyond HAIs as it can have a large impact on health outcomes through its influence on patient satisfaction, care seeking behaviour and staff moral3. The lack of safe WASH facilities in delivery rooms is frequently cited as a reason for women to prefer home delivery.

WHO-UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) Core Questions and Indicators for Monitoring WASH in Health Care Facilities in the Sustainable Development Goals

Progress on WASH provision in healthcare settings is currently being monitored as part of the Sustainable Development Goals (SDGs). At least 50% of all HCFs globally and in each SDG region must have basic WASH services by 2022, 80% by 2025, with the ultimate aim of 100% by 2030. Yet the majority of low- and middle-income countries have not undertaken national assessments, and hence lack information to raise awareness and set targets in pursuit of achieving this goal.

In 2018, the WHO-UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) published core questions and indicators for monitoring WASH in health care facilities in the Sustainable Development Goals.

The core questions are intended to be relevant in all countries and settings, and focused on the minimum criteria for provision of basic WASH services in HCFs. The indicators include definitions for ‘basic’ water, sanitation, hygiene, healthcare waste management and environmental cleaning.

To maximise the improvement of health outcomes from WASH services, it is essential to address underlying quality of care issues including ineffective IPC practices, especially around the time of birth. Soapbox were delighted to contribute to the development of these indicators and, in particular, focused on IPC measures such as environmental cleaning.

Environmental cleaning is an essential part of IPC. Assessing whether an area is considered “clean” is very subjective, and visibly clean may be very different from microbiologically clean (see Soapbox’s WASH & CLEAN study for more information). However, the new JMP indicators define HCFs which deliver on basic environmental cleaning practices as those which have protocols for cleaning, and where all staff with cleaning responsibilities have received training on cleaning procedures.

Asking about the existence of protocols for cleaning serves as an indication of the importance a HCF places on environmental hygiene. Likewise, those  who  clean  are  the  front  line  health  workers  in environmental hygiene and IPC, therefore HCFs must invest in this often neglected cadre by ensuring training enables them to perform their job to the highest standard.

The 2016 WHO Guidelines on Core Components of Infection Prevention and Control Programmes recommends delivery of IPC education and training to all staff, irrespective of level or position. Yet, our work with partners in India, Bangladesh, The Gambia and Zanzibar found that, on average, less than a third of the facilities surveyed delivered formal training to healthcare staff responsible for cleaning.

The JMP questions and indicators also provides a menu of options for countries or survey programs to expand upon the core question set. For environmental cleaning this could include assessing, for example, the availability of cleaning materials and products, staff knowledge of protocols and implementation of protocols.

This latest JMP document outlines ‘generic’ questions on the availability of basic WASH services which are required in all HCFs, recognising that additional questions may be required to assess WASH services in specialised service areas or wards. Soapbox are excited to continue working with partners to develop a set of indicators and questions specific to the requirements of WASH in delivery rooms, which will complement this set of facility-level indicators and questions.

1 Zaidi A, Huskins W, Thaver D, et al (2005). Hospital-acquired neonatal infections in developing countries. Lancet; 365:1175–1188

2 Halder A, Vijayselvi R, Jose R, (2015). Changing perspectives of infectious causes of maternal mortality. J Turk Ger Gynecol Assoc; 16:208–213

3 Bouzid M, Cumming O, Hunter PR (2018). What is the impact of water sanitation and hygiene in healthcare facilities on care seeking behaviour and patient satisfaction? A systematic review of the evidence from low-income and middle-income countries. BMJ Global Health; 3:e000648.