Systematic review and meta‐analysis: association between water and sanitation environment and maternal mortality

• Published in: Tropical medicine & international health 2014-04, Vol.19 (4), p.368-387
• Main Authors: Benova, Lenka, Cumming, Oliver, Campbell, Oona M. R.
• Format: Article
• Language: English
• Subjects: Africa; Africa - epidemiology; Biological and medical sciences; Databases, Bibliographic; effect size; Female; General aspects; Humans; Maternal Mortality; Medical sciences; Mortality; Mothers; Obstetric Labor Complications - microbiology; Obstetric Labor Complications - mortality; Pregnancy; Pregnancy Complications, Infectious - etiology; Pregnancy Complications, Infectious - microbiology; Pregnancy Complications, Infectious - mortality; Risk factors; Sanitation; Sanitation - statistics & numerical data; Sepsis - complications; Sepsis - etiology; Sepsis - mortality; Sewage - adverse effects; Sewage - microbiology; Systematic review; Water; Water Microbiology; Water Pollutants - adverse effects; Water Supply - statistics & numerical data
• ISSN: 1360-2276; 1365-3156
• DOI: 10.1111/tmi.12275

Objective To assess whether the lack of water or the lack of sanitation facilities in either the home or in health facilities is associated with an increased risk of maternal mortality and to quantify the effect sizes. Methods Systematic review of published literature in Medline, Embase, Popline and Africa Wide EBSCO 1980. Results Fourteen articles were found. Four of five ecological studies that considered sanitation found that poor sanitation was associated with higher maternal mortality. Meta‐analysis of adjusted estimates in individual‐level studies indicated that women in households with poor sanitation had 3.07 (95% CI 1.72–5.49) higher odds of maternal mortality. Four of six ecological studies assessing water environment found that poor water environment was associated with higher maternal mortality. The only individual‐level study looking at the adjusted effect of water showed a significant association with maternal mortality (OR = 1.50, 95% CI 1.10–2.10). Two ecological and one facility‐based study found an association between a combined measure of water and sanitation environment and maternal mortality. Conclusions There is evidence of association between sanitation and maternal mortality and between water and maternal mortality. Both associations are of substantial magnitude and are maintained after adjusting for confounders. However, these conclusions are based on a very small number of studies, few of which set out to examine sanitation or water as risk factors, and only some of which adjusted for potential confounders. Nevertheless, there are plausible pathways through which such associations may operate. Objectif Evaluer si le manque d'eau ou l'absence d'installations sanitaires à domicile ou dans les établissements de santé est associé à un risque accru de mortalité maternelle, et quantifier les valeurs de l'effet. Méthodes Revue systématique de la littérature publiée dans Medline, Embase, Popline et Africa Wide EBSCO 1980. Résultats Quatorze articles ont été trouvés. Quatre des cinq études écologiques qui se sont intéressées l'assainissement ont constaté que le manque d'hygiène était associé à une mortalité maternelle élevée. La méta‐analyse des estimations ajustées dans les études individuelles a indiqué que les femmes dans les ménages avec une mauvaise hygiène avaient 3.07 (IC95%: 1.72–5.49) fois plus de chances de mortalité maternelle. Quatre des six études écologiques qui ont évalué l'environnement de l'eau ont constaté qu'un mauvais e