Study examines how water access and sanitation affect birth outcomes

A new study by researchers in the University of Iowa College of Public Health examines the complex relationships between water and sanitation access and social conditions on birth outcomes among women in India.

Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child illnesses and death. In low-income countries, the challenges women face to meet their basic water, sanitation, and hygiene (WASH) needs may be a major contributor to adverse health outcomes.

Kelly Baker, assistant professor of occupational and environmental health, and Will Story, assistant professor of community and behavioral health, co-authored the study.

Read more…

Additional Media Coverage

Water access and sanitation shape birth outcomes and earning potential (Mongabay)

Poor sanitation, harassment reasons for birth problems in India (The Hindu)

Water access and sanitation shape birth outcomes and earning potential (Investment Guru India)

Study looks at impact of water, sanitation, and social conditions on birth outcomes in India

photo of a woman collecting water in plastic potsA new study by researchers in the University of Iowa College of Public Health examines the complex relationships between water and sanitation access and social conditions on birth outcomes among women in India.

Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child illnesses and death. In low-income countries, the challenges women face to meet their basic water, sanitation, and hygiene (WASH) needs may be a major contributor to adverse health outcomes.

“Many homes in low-income countries have no private drinking water source. Women and girls are tasked with fetching water from outside the home, which can be physically stressful,” says Kelly Baker, assistant professor of occupational and environmental health, who co-authored the study. “In addition, homes often lack private toilet facilities, meaning women must use shared or public latrines or manage their sanitation needs in open spaces.”

A portrait of Kelly Baker, professor in the Department of Occupational and Environmental Health at the University of Iowa College of Public Health.
Kelly Baker

The lack of water and sanitation in the home forces women to navigate challenging, and sometimes personally threatening, social and environmental public conditions to collect water and to find a safe, private place to defecate, bathe, or manage menstruation, leading to psychosocial stress.

“Determining whether WASH-related stress—both physical and psychosocial—affects birth outcomes for women in low- and middle-income countries is critical for understanding whether the global prevalence of preterm birth and low infant birth weight could be reduced by improving the social and environmental conditions in which pregnant women seek clean water and proper sanitation,” says study co-author William Story, assistant professor of community and behavioral health.

For the study, which was published online Oct. 8, 2018, in PLOS ONE, the researchers used data from the India Human Development Survey . The survey asked women about their drinking water source, walking time to that source, time spent fetching water, sanitation (toilet) access, harassment of women and girls, local crime, whether community problems are solved collectively or individually, the amount of conflict within the community, as well as education, household wealth, and other characteristics.

portrait of William Story
William Story

The researchers 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. Of these women, 14.9 percent experienced premature birth and 15.5 percent delivered a low birth weight baby.

The study found that increased time daily spent fetching household water increased women’s risk of delivering a low birth weight baby. Open defecation and using a shared latrine within a woman’s building or compound were also associated with higher odds of low birth weight and preterm birth, respectively, compared to having a private household toilet.

Harassment of women and girls in the community also was associated with both low birth weight and preterm birth. The data also showed a possible association of local crime with low birth weight.

“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 low- and middle-income countries,” the researchers write. “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.”

Interventions that reduce domestic responsibilities related to water and sanitation and that change social norms related to gender-based harassment may reduce rates of PTB and LBW in India, the authors note.

Additional contributors to the study include Evan Walser-Kuntz and Bridget Zimmerman from the UI Department of Biostatistics. The paper is available online at https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205345.

The study was funded by a pilot grant from the University of Iowa College of Public Health. Funding for the original IHDS study was provided to the University of Maryland and the National Council of Applied Economic Research, New Delhi, by the National Institutes of Health.

Global visiting scholar will discuss HIV risk in Kenya Oct. 15

Global Visiting Scholar Nema Aluku poster

Cultural and Religious Influences on the Risk of HIV Infection among Women in Western Kenya

Global Visiting Scholar Nema Aluku

Monday, Oct. 15
12:30 to 1:30 p.m.
C217 CPHB
Lunch will be provided.

Nema Aluku, PhD, MPH, is a research associate at Tangaza University College in Nairobi, Kenya. Dr. Aluku’s research is focused on the influences of religion and culture on HIV/AIDS and maternal and child health outcomes. In addition to her work at Tangaza University College, Dr. Aluku continues to provide technical assistance to a variety of NGOs in East Africa related to gender, religion, and health. She previously worked with World Renew and served as their Health and HIV Program Manager for East and Southern Africa.

UI students contribute to research on Roma health disparities in Romania

Romania political map. Illustration.On the edge of the thriving city of Cluj, Romania, is the decidedly not thriving community of Pata Rât. Located at Cluj’s former city dump, it’s filled with ramshackle houses, little indoor plumbing, pollution, and dirt roads that quickly turn to mud.

The population is about 1,500 people and almost all of them are Roma, otherwise known by the pejorative term gypsies. They are scattered throughout Europe and are subject to discrimination wherever they live. Pata Rât is an example of this. Many of its residents, about 350 people, once lived in a residential neighborhood in Cluj until the government evicted them and forced them to move to a landfill.

Health Care Disparities

Far from jobs and schools in the city—the nearest bus stop is about a mile and a half away, on the other side of a rail yard—and forced to live in a literal dump of a neighborhood, the people of Pata Rât have suffered significant health issues as a result. This summer, a group of 13 University of Iowa students from across the campus traveled to Romania as part of the Minority Health and Health Disparities International Training Program (MHIRT), a research training internship program to encourage under-represented minorities to pursue health careers. Two of the students—Darian Thompson and Breanna Kramer—worked with the Roma population in Pata Rât, on projects led by mentors at the Cluj School of Public Health that quantifies what that impact has been and help improve the lives of the children who live there.

“They met with Roma and held focus groups to determine what the health care disparities are between the Roma and the general Romanian population,” says Rema Afifi, professor of community and behavioral health in the College of Public Health who coordinated the training grant. She notes that the Roma—who make up about 8 percent of Romania’s population—have much higher rates of poor health outcomes than the general population as a result of the social, economic, and environmental conditions that surround them.

The students spent ten weeks in Romania, guided and mentored by researchers at the Cluj School of Public Health at Babeș-Bolyai University who have been monitoring health issues among the Roma for many years. They performed field work gathering data, and computational work analyzing the data. What they found was a largely homogenous population of white, ethnic Romanians with little acceptance of minorities such as the Roma.

Discriminatory Attitudes

Darian Thompson, one of the students participating in the MHIRT research internship, points to surveys that show 56 percent of Romanians do not feel comfortable living near Roma and 38 percent would not agree to have a Roma as a friend. While Romania’s unemployment rate is 8 percent, among the Roma, it’s 34 percent, and most of those who are employed work in unskilled, low-wage jobs.

Thompson is an African-American and so he’s seen and felt racism in the United States. What he saw directed at the Roma in Romania less subtle and more abrasive than the discrimination directed against minorities in the U.S.

“I was surprised by how openly discriminatory the population was toward the Roma,” says Thompson, a junior pre-med major from Cedar Rapids. “I realized that while we still have a lot of issues to work out in the U.S., we’re still pretty accepting of minorities compared to people in other parts of the world.”

Thompson spent most of his ten weeks of the project analyzing data, comparing past statistics to newly gathered data while looking for changes and trends. Meanwhile, Breanna Kramer, a Master of Public Health student in the College of Public Health, was in the field, talking with the Pata Rât Roma about their health.

Helping Children Succeed

Kramer’s work was focused on measuring the effectiveness of a Cluj School of Public Health program that’s designed to help Roma children in Pata Rât succeed in school. Because of transportation difficulties and fear of discrimination, most Pata Rât parents keep their children in a local, segregated school in the community. But Kramer says the school is substandard and the language of instruction is their native Romani, instead of the Romanian they will need to learn to be successful.

The program helps the students by providing bus transportation to better quality schools, new clothing, access to showers, hot meals, and other assistance to better prepare them for learning. Kramer says that preliminary research suggests the program is working to fulfill family needs at a basic level.

“It’s taking that weight off their parents so the kids can go to school and get the education they need,” says Kramer, from Donnellson, Iowa. “But poverty and discrimination still exist, and for that to improve, large-scale institutional change needs to happen, which will take years.”

Afifi says funding for the training program came from the National Institute on Minority Health and Health Disparities, a federal agency designed to lead scientific research that improves minority health and reduces health disparities through promotion and support of the training of a diverse research workforce. All 13 of the UI students who participated were from minorities underrepresented in the health sciences.

Slideshow: A Taste of Fieldwork in Xicotepec, Mexico

A group of University of Iowa students spent their spring break in Xicotepec, Mexico, studying food systems as part of a service-learning course.

 

Thousands of tourists flock to Mexico for spring break every year, but few of them conduct field research during their visit like a group of University of Iowa students did in March.

Dubbing themselves the Public Health Posse, the team of seven undergraduate and graduate students along with instructor Brandi Janssen traveled to Xicotepec, a small city in central-eastern Mexico, as part of a weeklong, interdisciplinary service-learning course.

Coordinated with the support of Rotary International, the course has developed long-standing service projects with the UI colleges of pharmacy and dentistry. It was the first year that a group of public health students took part.

“Our task was to identify opportunities for future public health projects that would be beneficial to the community,” says Janssen. Because Janssen’s area of study is food systems, the needs assessment was framed through that lens.

“Mexico is seeing a significant rise in diabetes and obesity, so we looked at schools and the food environment overall. We photographed and mapped grocery stores and markets and spoke to local people to answer questions like, What is the access to fruit and vegetables? What is the proportion of junk food to healthy food in stores? What are the greatest needs?”

“Every time we passed a place that sold food, we took GPS coordinates on our phones,” adds course participant Nichole Nidey, a doctoral student in epidemiology. “Our goal was to create an interactive map of the area to see where there are gaps in availability of nutritious food.”

The “story map” incorporates photos the group took during visits to public and private schools, an orphanage, a university, a hospital, a bakery, DIF (a state-run family services program), markets, grocery stores, and a coffee factory.

“The local Rotary was critical to making connections,” Janssen says. “We had a Rotary host at the institutions we visited in the mornings. In the afternoons, we were our own and went out to talk to shopkeepers and vendors.”

Those unscripted afternoons—along with other unknowns that come with international travel—often stretched students in new ways.

“Unlike a structured lab or classroom environment, you can’t plan for everything. This is exploratory fieldwork,” explains Janssen, an anthropologist by training. “You get out there, try things, and talk to people.”

And sometimes you get lucky. The group didn’t have a translator, but fortunately two of the students spoke fluent Spanish. And though varied in ages and backgrounds, the students quickly gelled as a team.

For Nidey, the trip was well worth it. “As a PhD student, I don’t get a lot of time out in the field. I wanted to do public health work in the field instead of behind the computer. It was eye-opening to get a glimpse of life in Xicotepec.” Nidey was one of four students on the trip who received a Global Public Health Student Travel Grant offered by the college. The grants were made possible by a gift to the College of Public Health from Dale and Linda Baker, whose gift also supported Janssen’s travel. The course will be available again in spring 2019.

Going forward, Janssen reiterates “that public health is not a fly in–fly out kind of thing,” she says. “We need to put a lot of thought into the programs and make sure they are sustainable.”

Photos by Nichole Nidey, Brandi Janssen, Isabella Brauhn, Megan Helms, Cindy Chavez, Michael Parisi-Mercado, Jack Feng, and Kenni Stearns.

This story originally appeared in the spring 2018 issue of Insight magazine.