title: Where there is no toilet: water and sanitation environments of domestic and facility births in Tanzania.
abstract: BACKGROUND
  Inadequate water and sanitation during childbirth are likely to lead to poor maternal and newborn outcomes. This paper uses existing data sources to assess the water and sanitation (WATSAN) environment surrounding births in Tanzania in order to interrogate whether such estimates could be useful for guiding research, policy and monitoring initiatives.
  
  
  METHODS
  We used the most recent Tanzania Demographic and Health Survey (DHS) to characterise the delivery location of births occurring between 2005 and 2010. Births occurring in domestic environments were characterised as WATSAN-safe if the home fulfilled international definitions of improved water and improved sanitation access. We used the 2006 Service Provision Assessment survey to characterise the WATSAN environment of facilities that conduct deliveries. We combined estimates from both surveys to describe the proportion of all births occurring in WATSAN-safe environments and conducted an equity analysis based on DHS wealth quintiles and eight geographic zones.
  
  
  RESULTS
  42.9% (95% confidence interval: 41.6%-44.2%) of all births occurred in the woman's home. Among these, only 1.5% (95% confidence interval: 1.2%-2.0%) were estimated to have taken place in WATSAN-safe conditions. 74% of all health facilities conducted deliveries. Among these, only 44% of facilities overall and 24% of facility delivery rooms were WATSAN-safe. Combining the estimates, we showed that 30.5% of all births in Tanzania took place in a WATSAN-safe environment (range of uncertainty 25%-42%). Large wealth-based inequalities existed in the proportion of births occurring in domestic environments based on wealth quintile and geographical zone.
  
  
  CONCLUSIONS
  Existing data sources can be useful in national monitoring and prioritisation of interventions to improve poor WATSAN environments during childbirth. However, a better conceptual understanding of potentially harmful exposures and better data are needed in order to devise and apply more empirical definitions of WATSAN-safe environments, both at home and in facilities.
authors.affiliation: London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom.
authors.forename: Lenka
authors.initials: L
authors.lastname: Benova
authors.affiliation: London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, United Kingdom.
authors.forename: Oliver
authors.initials: O
authors.lastname: Cumming
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Bruce A
authors.initials: BA
authors.lastname: Gordon
authors.affiliation: Evidence for Action (E4A), Department of Obstetrics and Gynaecology, Bugando Medical Centre and Teaching Hospital, Mwanza, Tanzania.
authors.forename: Moke
authors.initials: M
authors.lastname: Magoma
authors.affiliation: London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom.
authors.forename: Oona M R
authors.initials: OM
authors.lastname: Campbell
mesh_terms: D036861:Delivery, Obstetric / Q000592:standards / Q000706:statistics & numerical data; D003906:Developing Countries; D005260:Female; D006306:Health Surveys; D006700:Home Childbirth / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008427:Maternal Health Services; D036801:Parturition; D012499:Sanitation / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D013636:Tanzania; D014881:Water Supply / Q000706:statistics & numerical data