A matter of birth and death
How clean water can save new mothers and their vulnerable newborns
The first mothers, with their tiny babes barely visible amid swathes of bright cloth, began arriving in the misty morning just after sunrise.
Some came on foot. Others hung off the back of piky-piky (motorcycles), travelling up to two hours to reach the Mlali Health Centre, a clinic in rural Mvomero district in Morogoro region, at the foot of the picturesque Uluguru mountains.
By 9 am the clinic’s open-air entrance was crowded with dozens of mums and babies, lining benches all along the walls and even out of the door.
Here they bring their babies to be weighed and immunised, to collect Vitamin A capsules, to hear weekly sessions on recognising illness, and how to keep babies healthy by boiling drinking water, and washing hands before food preparation and after using the toilet.
This clinic, one of 380 health facilities in this region of 2 million people, has struggled to provide the most fundamental of health care basics: water.
The municipal supply here is turned on only once or twice a week. New mothers giving birth in local health clinics are routinely asked to bring their own water — typically 40 to 60 litres, or two or three large jerrycans — while in labour to wash themselves, their babies and the delivery room.
The burden makes an already arduous journey for laboring women even more difficult, as they cross dark fields and deeply rutted roads on motorbike or even on foot.
It also isn’t enough. The water they bring is often drawn from rivers or mountain streams and unsafe. New mothers and their newborns are at high risk of infection because of it.
This month, WaterAid joins UNICEF, the UN Population Fund, the World Health Organisation, London School of Hygiene and Tropical Medicine and other organizations in a call for governments to do more to protect new mothers and their babies by focusing more on safe water, basic sanitation and hygiene practices in places where women give birth, whether at home or in healthcare facilities.
The call to action is part of a new paper in the journal PLOS Medicine, From joint thinking to joint action: A call to action on improving water, sanitation and hygiene for maternal and newborn health.
“We have known since Victorian times about the importance of clean water and good hygiene in birth. Yet today tens of thousands of mothers will be giving birth in places where doctors and midwives, if present, do not have access to clean water. The process of giving life should not mean unduly risking death,” said Yael Velleman, senior policy analyst, sanitation and health, at WaterAid and a co-author of the landmark paper.
“As governments work to help women and their babies survive childbirth, they must not neglect these basic building blocks of health care.”
The researchers are aiming their message at the UN itself. Next year, the UN is to finish negotiations on a new set of Sustainable Development Goals, which will serve as the blueprints for development aid and efforts. In part, these goals will pick up on any unfinished work from the original Millennium Development Goals, which expire in 2015.
This paper calls for universal access to water and sanitation by 2030 to be among those new goals, and to include water, sanitation and hygiene targets in goals on maternal and newborn health.
Tanzania is among the most difficult in Sub-Saharan Africa to be a mother. For every 100,000 live births in 2012, 390 women died in or shortly after childbirth — a figure that has improved from a high of 454 deaths in 2010.
A companion paper in the journal PLOS One revealed that as many as one in three births in Tanzania are happening in places without access to safe water, basic sanitation and good hygiene practice.
When a pregnant woman steps into a hospital to deliver her baby, it seems only reasonable to expect there will be water in the tap and a functioning toilet.
Yet this is not the case for a majority of healthcare facilities in Tanzania. The PLOS One research found only 44% of the facilities that deliver babies in Tanzania, and just 24% of their delivery rooms, have basic access to water and sanitation.
“Many women lose their lives as a result of giving life. We believe this should not happen,” said Dr Ibrahim Kabole, country representative for WaterAid in Tanzania, who said the lack of clean water, good hygiene and basic toilets is contributing to high rates of infection among new mothers, and their babies.
Improving water and toilets at a facility, he said, will reduce the chance of infection. But it also encourages mothers to seek out health facilities, rather than give birth at home with often poorly trained attendants.
The situation has improved at Mlali, where WaterAid Canada has worked with local partners to construct a massive 30,000 litre rainwater collection tank. It doubles as a reservoir to capture every drop of the limited municipal supply.
The tank, finished in early June, helps ensure a steady supply of water, even in the dry season. When the rains begin, the full tank will provide them with water enough for a month at a time.
It’s critical, because the water shortages have been a matter of life and death for new mothers and their tiny newborns.
Aisha Mkude, 38, was thrilled in January to deliver a son after three daughters. In heavy labour, she had clung to her brother’s wife and a neighbour on the back of a piky-piky for the 30 minute drive through the night to the hospital, on narrow red-dirt tracks cut through maize fields.
After delivering Aisha to the clinic, the two other women went out again to collect three jerrycans — 60 litres — of water for Aisha’s delivery, to wash her and the baby afterward. “It was the dry season, so they had to dig a bit to get the water from the river. This was the water I used,” Aisha remembered, sitting outside her small, dusty brick home. Her family, like most around them, farms maize and tomatoes; she also runs a small tea stand serving tea and snacks to passers-by to supplement their income. There is no running water here; drinking water is purchased from a vendor, and water for washing and cleaning is fetched from a nearby spring.
Her son, she said, was delivered smoothly. “The problems happened afterwards.”
“After the discharge from the health centre I came home with my husband. After two days my child got sick. I advised my husband to take him back to the health clinic. He had a fever.”
The baby’s umbilical stump was oozing with infection. The nurses prescribed antibiotics, which his mother administered. Still, he worsened, and died at just seven days old.
He was too small to have even been given a name.
“I wasn’t told how the baby got infected. But what I think is the water from the river could have been the source. This water is used by a lot of people,” Aisha said.
“When I look back it is a sad story for me. The day I brought him home I felt great, because I had no problems in the delivery and I had a lot of energy. I was happy. It was a huge moment and a very joyful moment because three of my children are girls — to have a boy child was a glorious moment for me. My son was delivered at 3.5 kg, he had no other problems until he started getting sick from the infection,” she says.
Such a death, from infection caused by dirty water, is almost unthinkable in the UK. But in Tanzania, like many other developing countries, sepsis — blood poisoning that comes from raging infection — is a leading cause of death among newborns, responsible for some 20% of newborn deaths along with tetanus and meningitis.
In hospitals in the developed world, it is rare, thanks to the presence of safe water and good hygiene practices in homes, hospitals and clinics with proper toilets.
The midwives at the clinic say it was frustrating to work without a steady supply of water.
“We were feeling very bad because we didn’t have enough water. We felt we were working in a difficult environment. Sometimes we felt demoralized, because how can you work in such an environment, in a health facility without water?” said midwife Esther Mongi, who has worked at the clinic for 10 years.
The installation of the rainwater tank and new latrines, she and her colleagues said, will make an enormous difference.
The rainwater tank allows them to keep the clinic cleaner and to wash hands between patients more easily, as well as provide a safe source of water for bathing.
The new latrines will relieve the lengthy queues for the old single latrines, which led many patients to give up waiting and relieve themselves in a field nearby instead, soiling themselves and their clothing and increasing the risk of infection in the process.
Patients already notice the difference, too.
“I feel that the environment is cleaner and there is more water,” said Flora Adrian, 32, cradling her tiny son Melckzedek while awaiting an immunisation at the clinic. He was born less than a week before the rainwater tank started functioning, on a night when the municipal supply was off.
“The last time I came to deliver, there was no water, so we had to go far to fetch water from here,” she recalled. When she, her husband and her mother arrived at the clinic on motorbike, at 4 am, her husband then had to leave his laboring wife to find water. “It was a half-hour on the motorbike to get water … I felt very bad to find there was no water.
“The birth was ok, everything was fine,” she said. “But when the water is not there, you cannot feel that you are clean.”
Now, with the project complete, the midwives are looking forward to more experiences like that of Mary Musa.
Mary, a young woman with a brilliant smile, delivered her baby two months after the tank was complete. Her first three children were born elsewhere, in clinics where bringing jerrycans of water along for the delivery is routine.
When it came time for her fourth pregnancy, though, she was convinced to go to Mlali because of its growing reputation.
On the day of our visit, two weeks after Ely’s birth, she cannot contain her joy at the arrival of her tiny, sleepy son.
She lives 10 km away from Mlali clinic, a journey that took two hours over rocky fields on foot. There was no money to hire a car, and her pain was too great for a motorbike taxi.
They arrived at the clinic at 3 am, in darkness. Ely was born a few hours later, a strapping baby boy.
“I felt so great after the delivery of my child though he was big, about 4.5 kilos. I was in pain after delivery, but I was so happy,” she said, smiling as she cradled her sleeping son.
“When I went for my delivery, the environment was so clean and all the cloths were clean. When I reached the health centre I saw there were three other women who had given birth before me, and even so the environment was so clean,” she said.
“Water is very important to women who are delivering babies. Water is something that can make them clean.”
WaterAid’s Christmas campaign, Child of Mine, is raising funds to help save children’s lives by providing access to safe water, basic sanitation and hygiene education. Without these, children are more vulnerable to the three main killers of undernutrition, pneumonia and diarrhoea. Nearly 1,400 children die each year of preventable diarrhoeal diseases linked to unsafe water and a lack of sanitation and hygiene.
All Photos: WaterAid/ Eliza Deacon