Research Article: Impact of social capital, harassment of women and girls, and water and sanitation access on premature birth and low infant birth weight in India

Date Published: October 8, 2018

Publisher: Public Library of Science

Author(s): Kelly K. Baker, William T. Story, Evan Walser-Kuntz, M. Bridget Zimmerman, Cheryl A. Moyer.


Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes.

This cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification. The relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affects PTB and LBW among Indian women. Interventions that reduce domestic responsibilities related to water and sanitation and change social norms related to gender-based harassment may reduce rates of PTB and LBW in India.

Partial Text

Increasing the number of women who successfully carry a healthy, nourished infant to term is critical for achieving the Sustainable Development Goals (SDGs). Spontaneous preterm birth (PTB), caused by onset of labor or rupture of the fetal membranes before 37 completed weeks’ gestation, is one of the leading global causes of death in neonates and children under five years of age, as well as maternal complications (e.g. placental previa and mortality) [1]. An estimated 12.9 to 15 million PTBs occur each year, with 60 to 85% of these births occurring in Asia and sub-Saharan Africa [2, 3]. Low birth weight (LBW), whether term or preterm status, is an even more common public health issue. In 2012, an estimated 23.3 million infants were born small for gestational age in low- and middle-income countries (LMICs) alone, of which 12.2 million infants were LBW (< 2,500 grams) [4]. Infants in LMICs who are born prematurely or at LBW experience a high risk of death, and are more likely to experience gastrointestinal infections, respiratory infections, growth stunting, and cognitive impairment in later childhood [5–12]. Critically, PTB rates appear to be rising [2], suggesting morbidity and mortality caused by PTB and LBW may rise as well. Early implementation of preventive interventions with women who are at high risk for PTB or LBW in the pregnancy period, before delivery occurs, could reduce a substantial amount of morbidity and mortality among newborns in LMICs [13]. Of 25,789 women who participated in both waves of the IHDS, 7,926 (30.73%) women delivered an infant between 2004/2005 and 2011/2012 and thus were eligible for this study (Fig 1). PTB and LBW infants occurred in 14.86% (1,172 out of 7,889) and 15.52% (1,230 out of 7,926) women, respectively. Both outcomes occurred jointly in 312 (3.95%) of women, which suggests that PTB and LBW are distinct outcomes. Participating women lived in 2,098 villages and urban blocks from across India (range 1–23 per village), in 360 Districts (range 1–87 per district), in 22 States (22–1,097 per state). This represents 56.3% of India’s 640 Districts and 61.1% of 36 States in 2011. Preterm birth and low infant birth weight are among the leading causes of neonatal and early childhood morbidity and mortality in LMICs, like India, and prevalence rates in Africa and Southeast Asia are rising [1–3]. The rising rates of PTB and LBW in LMICs underscore the importance of identifying targeted interventions that prevent these birth outcomes and subsequent child morbidity and mortality. However, the wide range of biological, environmental, and social risk factors complicates identifying preventive interventions for PTB and LBW. This study contributes to the limited evidence related to environmental causes of PTB and LBW by demonstrating that lack of household WASH infrastructure and social factors, like crime and harassment of women and girls, are risk factors for adverse birth outcomes in women in LMICs. In particular, this study uses a large, nationally representative cohort of Indian women to demonstrate the importance of the lack of access to nearby water sources, lack of access to a toilet, crime, and harassment as risk factors for PTB and LBW. Additionally, the findings suggest that gender norms that sanction harassment of women and girls and place the burden of household water fetching on women are key determinants of vulnerability to PTB and LBW among Indian women.   Source:


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