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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 WATSANsafe. 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.
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). 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’. 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. No uniform definitions of acceptable or ‘improved’ WATSAN environments of health facilities are currently available for international monitoring. We classified the WATSAN environment in facilities using the limited data collected by the SPA to capture facility environments with different risk profiles and the requisite equipment/supplies for infection control measures. The survey collected information on the WATSAN environment of the facility as a whole and a more detailed description of the delivery room environment. We characterised both environments, defining ‘WATSAN-safe’ environments as those which fulfilled both the ‘improved’ water and ‘improved’ sanitation requirements (Table 2). We reasoned that in hospitals, the delivery room may better describe the environment where the birth occurred, but in smaller facilities, such as dispensaries and health centres, the overall facility environment may be indistinguishable from the delivery room environment. WATSAN profiles of both these environments were therefore used to calculate uncertainty intervals. In analysing both DHS and SPA data we accounted for the complex survey sampling (clustering, stratification and sample weights) by using the svyset command in Stata/SEv.13 in order to produce point estimates and their 95% confidence intervals. To assess the WATSAN environment of facility births, we combined the level of health facility where the birth occurred (dispensary, health centre or hospital) with the weighted average of WATSAN-safe facilities of that level in the zone where the birth occurred, from the SPA. No information was available about the WATSAN environment for births occurring in ‘other locations’. We combined the estimated number of WATSAN-safe births in the three locations (home, health facility, other) to estimate of the proportion of all births in WATSAN-safe environments, by zone and nationally. The midpoint estimate and the best and worst case scenarios, representing the range of uncertainty, were obtained using the scenarios provided in Table 3. DHS: Respondents were informed about the purpose of the survey before the start of the interview, informed that their participation was voluntary, and that all information provided was confidential and de-identified. The respondent’s verbal consent, if obtained, was noted on the questionnaire with a signature of the enumerator. SPA: Informed consent was obtained from the facility in-charge and from all respondents for the facility audit questionnaires. Prior to commencing the Delivery and Newborn Care questionnaire module, the enumerator located the manager or most senior health worker and provided them with the details of the survey. The respondent was told the study aims, that the facility was selected randomly, and that no patient names would be recorded or shared. They were informed that participation was voluntary, and that the information collected might be used by the Ministry of Health or other organisations seeking to improve the planning and delivery of health services, and that the name of the facility will be removed from the dataset. Verbal consent of the responding health worker, if obtained, was noted on the questionnaire with a signature of the enumerator. Both the DHS and the SPA surveys used in this study were implemented by the National Bureau of Statistics and the Office of the Chief Government Statistician – Zanzibar; in collaboration with the Ministry of Health and Social Welfare. ICF Macro provided technical assistance for the survey through the MEASURE DHS programme and The United States Agency for International Development (USAID) funded this technical assistance. The ethical nature of both surveys, including the method of obtaining and recording informed consent received approval from local government authorities. The secondary analysis of the de-identified datasets was approved by the Observational/Interventions Research Ethics Committee at the London School of Hygiene and Tropical Medicine. Both sources of data are available at www.measuredhs.com.
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