Swimming upstream: why sanitation, hygiene and water are so important to mothers and their daughters



Clarissa BrocklehurstI; Jamie BartramII,*

IWater, Sanitation and Hygiene Section, United Nations Children's Fund (UNICEF), New York, United States of America
IIThe University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, USA



So many things impact the health and well-being of women as they navigate their childbearing years. The most under-recognized of these are water, sanitation and hygiene, yet the benefits of these basic interventions are extensive and self perpetuating, impacting women and their daughters from generation to generation.

Let us start with a pregnant woman. She is likely to have to collect and carry water for her baby's delivery from a hand pump outside her home; globally more than 40% of households do not have a water supply on their premises. If she is very unfortunate she will be among the 13% who do not even have a hand pump and rely on an unimproved water source, made even more risky by the fact that most people in her community lack even a basic toilet. These unhygienic conditions take on new significance when she weans her child. Diarrhoea kills 1.5 million children every year 1 and there is a strong link between diarrhoea and malnutrition.

By around the age of six, the child should be going to school. However, if this child is a girl, much of her time will be needed for tasks at home, including water collection. In half of all households worldwide, water is carried to the home and in 72% of households, women and girls are the primary water collectors. Girls are twice as likely as boys to be the carriers. 2 Our girl child is exposed to an increasing range and burden of infections as she encounters the world beyond her home. Intestinal helminths affect 400 million – one in three – schoolchildren. Infestations such as hookworm reduce physical growth and impair intellectual development. 3 Girls weakened by energy loss, intestinal worms and repeated infections are predisposed to anaemia that takes on new significance as they enter menarche, which may also mark the end of their limited schooling. The lack of school toilets with privacy and facilities for menstrual hygiene contribute to sporadic attendance and drop out. If our girl child does not overcome these constraints and she drops out of school, she will likely face early marriage and early childbearing.

The vicious cycle described here can be reversed. The importance of water, sanitation and hygiene for health and development is reflected in a target of the United Nations Millennium Development Goals: to halve, between 1990 and 2015, “the proportion of people without sustainable access to safe drinking water and basic sanitation”.

The first hurdle our mother and child encountered was the unsanitary conditions and lack of hygiene at the time of birth. A study in Nepal showed that hand-washing by birth attendants and mothers increased newborn survival rates by up to 44%. 4 Hygiene promotion has been shown to be one of the most cost-effective health interventions, particularly with the use of marketing techniques based on those used by private companies.

In sanitation, though global progress has been poor, some developing countries achieved up to 60% reduction in the proportion of their population lacking improved sanitation. It is likely that political will, modest financing cleverly applied and a focus on changing behaviour and social norms, not just installing infrastructure, contributed to this rapid progress. Building demand for toilets, especially among those people who have practiced open defecation all their lives, helps trigger household investments. Evidence that these approaches are effective suggests that accelerated progress is possible.

Barriers in providing drinking-water can also be overcome. Innovations include low-cost drilling techniques and cheaper hand pumps, the use of locally-managed, small-scale systems, entrepreneurial water kiosks and civil society intermediation between poor communities and service providers. Providing water, sanitation and hygiene in schools is increasingly a priority for ministries of education in developing countries. Emerging designs for toilets that incorporate privacy and facilities for menstrual hygiene provide a multitude of benefits. For instance, women who have been to school are less likely to die during childbirth – each additional year of education prevents two maternal deaths for every 1000 women. 5

The vicious cycle in which inadequate water, sanitation and hygiene contributes to keeping women in poor health, out of education, in poverty and doomed to bearing sickly children can be reversed. The tools to do this exist. Water, sanitation and hygiene also enable women to play roles in their community's development, including, of course, decision-making and management of water and sanitation systems.



1. Diarrhoea: why children are still dying and what can be done. New York: United Nations Children's Fund; 2009.         

2. Global annual assessment of drinking-water and sanitation, 2010 report. Geneva: World Health Organization; 2010.         

3. Raising clean hands. New York: United Nations Children's Fund; 2010.         

4. Rhee V, Mullany LC, Khatry SK, Katz J, LeClerq SC, Darmstadt GL et al. Maternal and birth attendant hand washing and neonatal mortality in Southern Nepal. Arch Pediatr Adolesc Med 2008;162:603–8. doi:10.1001/ archpedi.162.7.603 PMID:18606930


5. The state of the world's children 2004: girls, education and development. New York: United Nations Children's Fund; 2004.         



*Correspondence to Jamie Bartram (e-mail: jbartram@email.unc.edu)

World Health Organization Genebra - Genebra - Switzerland