Intended for healthcare professionals

Feature Mother and child health

The global push for institutional childbirths—in unhygienic facilities

BMJ 2016; 352 doi: (Published 10 March 2016) Cite this as: BMJ 2016;352:i1473
  1. Jocalyn Clark,
  2. freelance writer
  1. Dhaka
  1. j.clark{at}

Healthcare facilities offer professional assistance to women giving birth, writes Jocalyn Clark, but many in developing countries are filthy, lacking clean water and sanitation

Increasing and regularly monitoring the number of women giving birth in institutions has been central to international strategies to improve the health of mothers and babies in the developing world. In India, the $200m (£141m; €184m) a year Janani Suraksha Yojana programme pays women to give birth in healthcare facilities rather than at home, as is tradition. Bangladesh and Nepal have similar conditional cash transfer programmes.

This push has largely neglected a sad irony: in much of the developing world, where 99% of maternal and newborn deaths occur, hospitals and other healthcare facilities are in a poor state.

In an unprecedented analysis of water, sanitation, and hygiene (WASH) in healthcare facilities in low income countries, the World Health Organisation recently reported that 38% have no decent water source.1 This leaves doctors, nurses, and midwives struggling to care for patients—and WHO “embarrassed.”2 One fifth of facilities surveyed in 54 countries had inadequate sanitation, and 35% lacked water and soap for healthcare providers and patients to wash their hands.

Mother and baby risk infection

Poor hygiene is of special concern in labour wards, said Wendy Graham, a maternal mortality expert from the University of Aberdeen who is raising awareness of WASH. In dirty conditions, mother and baby risk infections from many sources, she said.

Infection may be introduced to the genital tract during delivery from poor hand hygiene or contaminated surfaces, which can lead to death from puerperal sepsis.3 When dirty hands, surfaces, or blades are used, wounds from cutting the umbilical cord, perineal tears, and caesarean section introduce routes of transmission of infection. Lack of water and sanitation make it impossible for providers to ensure clean hands and …

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