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Author Notes:

Email Address: ppanigrahi@unmc.edu

Conceived and designed the experiments: PP BKP KKB AD BSD. Performed the experiments: BKP. Analyzed the data: BKP.

Contributed reagents/materials/analysis tools: AD KKB OC MCF. Wrote the first draft of the manuscript: BKP PP.

Contributed to the writing of the manuscript: BKP PP. Agree with the manuscript’s results and conclusions: BKP KKB AD OC MCF RS BSD PP.

Enrolled patients: BKP BSD RS. All authors have read, and confirm that they meet, ICMJE criteria for authorship.

The authors wish to thank the other members of our research consortium: Belen Torondel, Bethany Caruso, Kristyna Rae Solawetz Hulland, Krushna Chandra Sahoo, Padmalaya Das, Pravas Ranjan Misra, and Robert Dreibelbis.

Also, we are indebted to the programme manager, supervisors, data entry personnel, and many field staff who administered the surveys and collected measurements for this study.

We would like to express our appreciation for the support from study participants, and for the Anganwadi workers and Accredited Social Health Activists for assisting in this project.

However, the views expressed do not necessarily reflect DfID’s official policies or the policies of WSSCC.

The funders of the study had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The first and corresponding authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.


Research Funding:

This work was made possible with UK aid from the Department for International Development (DfID), as part of the SHARE research programme, and support from the Water Supply and Sanitation Collaborative Council (WSSCC).

Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study

Journal Title:

PLoS Medicine


Volume 12, Number 7


, Pages e1001851-e1001851

Type of Work:

Article | Final Publisher PDF


Background The importance of maternal sanitation behaviour during pregnancy for birth outcomes remains unclear. Poor sanitation practices can promote infection and induce stress during pregnancy and may contribute to adverse pregnancy outcomes (APOs). We aimed to assess whether poor sanitation practices were associated with increased risk of APOs such as preterm birth and low birth weight in a population-based study in rural India. Methods and Findings A prospective cohort of pregnant women (n = 670) in their first trimester of pregnancy was enrolled and followed until birth. Socio-demographic, clinical, and anthropometric factors, along with access to toilets and sanitation practices, were recorded at enrolment (12th week of gestation). A trained community health volunteer conducted home visits to ensure retention in the study and learn about study outcomes during the course of pregnancy. Unadjusted odds ratios (ORs) and adjusted odds ratios (AORs) and 95% confidence intervals for APOs were estimated by logistic regression models. Of the 667 women who were retained at the end of the study, 58.2% practiced open defecation and 25.7% experienced APOs, including 130 (19.4%) preterm births, 95 (14.2%) births with low birth weight, 11 (1.7%) spontaneous abortions, and six (0.9%) stillbirths. Unadjusted ORs for APOs (OR: 2.53; 95% CI: 1.72–3.71), preterm birth (OR: 2.36; 95% CI: 1.54–3.62), and low birth weight (OR: 2.00; 95% CI: 1.24–3.23) were found to be significantly associated with open defecation practices. After adjustment for potential confounders such as maternal socio-demographic and clinical factors, open defecation was still significantly associated with increased odds of APOs (AOR: 2.38; 95% CI: 1.49–3.80) and preterm birth (AOR: 2.22; 95% CI: 1.29–3.79) but not low birth weight (AOR: 1.61; 95% CI: 0.94–2.73). The association between APOs and open defecation was independent of poverty and caste. Even though we accounted for several key confounding factors in our estimates, the possibility of residual confounding should not be ruled out. We did not identify specific exposure pathways that led to the outcomes. Conclusions This study provides the first evidence, to our knowledge, that poor sanitation is associated with a higher risk of APOs. Additional studies are required to elucidate the socio-behavioural and/or biological basis of this association so that appropriate targeted interventions might be designed to support improved birth outcomes in vulnerable populations. While it is intuitive to expect that caste and poverty are associated with poor sanitation practice driving APOs, and we cannot rule out additional confounders, our results demonstrate that the association of poor sanitation practices (open defecation) with these outcomes is independent of poverty. Our results support the need to assess the mechanisms, both biological and behavioural, by which limited access to improved sanitation leads to APOs.

Copyright information:

© 2015 Padhi et al.

This is an Open Access work distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/).

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