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WASH and CLEAN on the Labour
Ward: A Situation Analysis in
India & Bangladesh
Team India
Prof D V Mavalankar
Prof K Vora
Prof D Saxena
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Latest SRS reports cites…..
 MMR in India around 200 per
100,000 LB
 Gujarat MMR about
142/100,000LB
 Documented Increased use of
health facilities
 Institutional deliveries reduce the
risks of infections but there are
poor infection control practices in
labour and delivery units , that can
cause puerperal sepsis and other
infections of childbirth.
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Descriptive review from India shows that
 Puerperal sepsis second most common cause after
hemorrhage, accounting for approximately 15% of all
maternal deaths.
 Hemorrhage can also have infection as an underlying
contributory factor .
 Studies from northern India reveals sepsis responsible for
over 35% of maternal deaths & leading cause of maternal
death, responsible for 41.9% of deaths in Southern India.
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Global evidences shows …..
 Robust evidence-based links between poor hygiene practices
and environment at the time of birth contributing to lifethreatening infections in mothers and babies.
 Poor WASH and infection control in institutional facilities not
only increases the iatrogenic risks to mothers, babies and
indeed health care providers, but also impacts on women’s
satisfaction with care at the time of birth.
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To conclude……………………..
• Health gain is seriously undermined if health facilities
do not have capacity to cope with increased demand,
in terms of trained healthcare workforce and physical
environment including WASH , this can inevitably lead
to an increase in infection-related morbidity and
mortality.
• Misuse of antibiotics, particularly around childbirth,
can also lead to significant drug resistance that can
increase the healthcare costs.
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Objectives 1
• Situation analysis of the determinants, processes
and effectiveness of cleaning practices on labour
wards/ maternity units in India and Bangladesh
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Objectives 2
• Understand how the underlying determinants –
both the contextual drivers, such as WASH, and
those relating to individual actors can influence
cleaning practice and drive cleanliness and safety of
the birth environment and identify effective,
acceptable and sustainable interventions in the
longer-term.
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Conceptual framework
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Methodology
• Multi Site Study
• Gujarat State, India, and in Mymensingh District and Dhaka
City, Bangladesh
• Project involves developing and pilot testing tools for
capturing levels of cleanliness objectively and the
determinants (structures), processes and outcomes of
cleaning of the labor ward.
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Methodology ………
• Application of tools to a small stratified sample of maternity
units to the test determinants of WASH in terms of
• Infrastructure, management, supervision and cleaning
resources,
• Individual drivers such as social norms (the structures), the
cleaning practices in terms of who cleans what and how
(the processes),
• Effectiveness as measured satisfaction and acceptability of
user and provider in terms of visual cleanliness, and
• by basic microbiological assessment in terms of safety of
the healthcare environment (the outcomes).
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Three phases to current project
1. Formative : develop a “toolbox” to capture objectively levels
of cleanliness and to reveal key determinants
2. Situation analysis : to apply toolbox to 8-12 maternity units
in Gujarat State, and 10 units in Mymensingh District & Dhaka
city in Bangladesh
3. Synthesis & communication : to revise toolbox & share
findings (& prepare proposal for improvement intervention)
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Methodology ……….
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 Mixed-methods approach, combining qualitative and
quantitative
 Formative phase - focused on 2 maternity units
◦ Refinement of the conceptual framework
◦ Stakeholder analysis
◦ Development of photo methodology-Photovoice
◦ Development of the processes and protocols
◦ Focus group discussions with stakeholders
◦ Qualitative assessment of key parameters of
healthcare environment
◦ Convening of synthesis workshop
◦ Microbiology sample collection & culture
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Photo Elicitation technique …………
 An innovative method have not been used previously in
connection with healthcare environments including WASH.
 Photo-elicitation asks participants to react to photographic
prompts-generating discussion, debate, and insights not
gained through more traditional “direct questioning”
methods of data collection.
 Furthermore, engaging participants in the photo-elicitation
method has been found to have an impact in terms of
empowerment and education, suggesting its relevance to
future intervention work
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Modules already designed for implementation ….





Head of Hospital Interviews
FGD (or interviews) with other relevant managers
Facility Document Capture & Review
Facility Questionnaire
Checklist/ Walk Through micro-biology and photography
during walk-through by research associate
 Participatory Photography Workshops – Cleaners/ Providers
 Semi-structured, photo-prompted interviews or FGDs –
Cleaners/ Healthcare Providers
 Interviews/ FGD with women users
Permission from State & IEC granted
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Situation analysis
 After formative phase and tool development
 8-12 maternity units will be included for situational
analysis in Gujarat using tools developed during
formative phase
 Synthesis and communication of findings:
 to revise toolbox & share findings (& prepare proposal
for improvement intervention)
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Proposed outcome of project
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 Findings of the study will be shared with stakeholders
including government to help improving cleaning practices
and infection control in labor rooms
 Findings will also assist in better understanding of infection
control in labour rooms and general cleanliness of hospitals.
 Sample collection and culture of basic microbial samples
can provide useful evidence to support the need for action
and subsequently can be used to evaluate improvement
interventions.
 The study will explore the innovative method photoelicitation in area of Public Health.
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References:
• Hogan MC, Foreman KJ, Naghavi M, Ahn S, Wang J, Makela SM, Lopez AD, Lozano R, Murray
CJL: Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress
towards Millennium Development Goal 5. Lancet 2010, 375:16091623. PubMed Abstract | Publisher Full Text
• Kumar R, Sharma AK, Barik S, Kumar V: Maternal mortality inquiry in a rural community of
north India.International Journal of Gynecology and Obstetrics 1989, 29:3139. PubMed Abstract |Publisher Full Text
• Kausar R: Maternal Mortality in India - Magnitude, Causes and Concerns.Indian Journal for
the Practising Doctor 2005, 2:2.
• Anandalakshmy PN, Buckshee K: Maternal mortality in a referral hospital in northern India:
a sixteen year review. Journal of Family Welfare 1997, 43:1-4.
• Rajaram P, Agrawal A, Swain S: Determinants of maternal mortality: a hospital-based study
from south India. Indian Journal of Maternal and Child Health 1995, 6:7- PubMed Abstract
• Special Bulletin on Maternal Mortality in India 2009-11
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THANKS