title: Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study.
abstract: 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.
  
  
  RESULTS
  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.
authors.affiliation: Asian Institute of Public Health, Bhubaneswar, India.
authors.forename: Bijaya K
authors.initials: BK
authors.lastname: Padhi
authors.affiliation: College of Public Health, University of Iowa, Iowa City, Iowa, United States of America.
authors.forename: Kelly K
authors.initials: KK
authors.lastname: Baker
authors.affiliation: Asian Institute of Public Health, Bhubaneswar, India.
authors.forename: Ambarish
authors.initials: A
authors.lastname: Dutta
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Oliver
authors.initials: O
authors.lastname: Cumming
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America.
authors.forename: Matthew C
authors.initials: MC
authors.lastname: Freeman
authors.affiliation: Asian Institute of Public Health, Bhubaneswar, India.
authors.forename: Radhanatha
authors.initials: R
authors.lastname: Satpathy
authors.affiliation: Asian Institute of Public Health, Bhubaneswar, India.
authors.forename: Bhabani S
authors.initials: BS
authors.lastname: Das
authors.affiliation: College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, United States of America.
authors.forename: Pinaki
authors.initials: P
authors.lastname: Panigrahi
mesh_terms: D003672:Defecation; D005260:Female; D006801:Humans; D006920:Hygiene; D007194:India; D007230:Infant, Low Birth Weight; D011247:Pregnancy; D011256:Pregnancy Outcome; D047928:Premature Birth / Q000453:epidemiology; D018570:Risk Assessment; D012424:Rural Population