Open defecation affects pregnancy outcomes too, new study finds

The Wire
July 7, 2015

Eradicating open defecation has become one of the biggest, and most daunting, challenges faced by the Narendra Modi government. Poor sanitation practices like open defecation have been known to cause cause stunting in children, not to mention a contamination of water resources leading to cholera, typhoid and dysentry. The mechanism of these adverse outcomes is the effect of the unhygienic biosphere the open fecal matter results in, festering bacteria, viruses and other contaminants that poison food and water.

In the same way, a group of researchers from India and the United States asked themselves: can open defecation also affect pregnancy outcomes? “One of the possible consequences, apart from diarrhea and other gastrointestinal infections due to fecal oral contamination, of open defecation could be on women’s genito-urinary tract due to the proximity of the vagina to the anus,” Pinaki Panigrahi, a professor of epidemiology at the University of Nebraska Medical Centre and an author of the study, told The Wire.

And if this is indeed a plausible mechanism of infection, the adverse effects will not just be experienced by the mother but by the child as well. To investigate, Dr. Panigrahi and her colleagues – including from the Asian Institute of Public Health, Bhubaneshwar – enrolled a cohort of 670 women in their first trimesters of pregnancy from four villages from the Sundargarh and Khurda districts of Odisha. The state was chosen because it has an infant mortality rate of 53 per 1,000 live births and a maternal mortality rate of 235 per 100,000 women of reproductive age – both very high – apart from 75% of the population practicing open defecation. Then, the women’s health and sanitary practices were documented until they gave birth.

Locations of the villages in Odisha state.
Locations of the villages in Odisha state.

The team found a “statistically significant association” between open defecation and pregnancy outcomes, which means there was a correlation between the two that persisted in various circumstances. Of the 670 women enrolled, 667 completed the study. Of those 667, 172 (28.2%) experienced adverse pregnancy outcomes – such as preterm births (130), babies with low birth-weight (95), spontaneous abortions (11) and stillbirths (6). However, despite weaning out many confounding factors, the study does not make a distinction between pregnancy outcomes due to open defecation and outcomes due to hand-washing practices after defecation.

For example, in the cohort, 58.17% (388) did not have access to latrines. Among those who did have access, less than half – 45.8% – used it on a regular basis. The team also found that 58% of pregnant women did not wash their hands with soap or detergent after defecation, a number that clearly includes a lot of the women who had indoor loos as well. With this in mind, the study’s distinction between indoor and outdoor defecation boils down to how hand-washing practices were affecting the maternal outcomes of pregnant women. This is highlighted by the fact that out of the 279 women who had access to a latrine, only 136 had a washing station at or near it – while 278 women out of the total 667 reported using a soap or detergent after defecating.

Adverse pregnancy outcomes stratified by sanitation characteristics.
Adverse pregnancy outcomes stratified by sanitation characteristics.

The team was also able to find that it didn’t matter if the women who defecated in the open were wealthier or poorer, their odds of having a sub-par pregnancy were similar. What really improved the odds of a healthy pregnancy was education. An influential study by Thomas Clasen of Emory University, Georgia, also had similar findings in October 2014: it wasn’t enough to put up accessible latrines but to make women understand that they needed to use them. Apart from reinforcing old attitudes, however, the findings suggest a new ‘front’ on which to tackle the sanitation crisis facing the country from a policy standpoint.

But before that, to establish the effects of open defecation exclusively on pregnancy, the mechanism of infection needs to be found. “What does open defecation do? Induces an infection in the urogenital tract? A type of inflammation due to an infection or aberrant bacterial colonization of the vaginal tract? Or simply raises the stress level of the pregnant woman while going out to defecate in harsh environments, being exposed to unknown men, or simply withholding the urge to defecate or urinate?” We don’t know, and this is what studies of the future will focus on, according to Dr. Panigrahi.

Anyway, they excluded practices like smoking, alcohol use, history of STDs, antenatal complications and history of abortions. The rationale is that smoking, for example, doesn’t affect the relationship between open defecation and pregnancy outcomes even if it affects pregnancy by a separate mechanism of its own. Dr. Panigrahi asserts: “After including dozens of factors, we still find a significant association. By adding one or two new factors if at all will have a minimal dent on the statistical model we used.”

The study was published in the open-access journal PLOS Medicine on July 7.