Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes. This cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification. The relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affects PTB and LBW among Indian women. Interventions that reduce domestic responsibilities related to water and sanitation and change social norms related to gender-based harassment may reduce rates of PTB and LBW in India.

Stronger health systems, with an emphasis on community-based primary health care, are required to help accelerate the pace of ending preventable maternal and child deaths as well as contribute to the achievement of the Sustainable Development Goals (SDGs). The success of the SDGs will require unprecedented coordination across sectors, including partnerships between public, private, and non-governmental organizations (NGOs). To date, little attention has been paid to the distinct ways in which NGOs (both international and local) can partner with existing national government health systems to institutionalize community health strategies. In this paper, we propose a new conceptual framework that depicts three primary pathways through which NGOs can contribute to the institutionalization of community-focused maternal, newborn, and child health (MNCH) strategies to strengthen health systems at the district, national or global level. To illustrate the practical application of these three pathways, we present six illustrative cases from multiple NGOs and discuss the primary drivers of institutional change. In the first pathway, “learning for leverage,” NGOs demonstrate the effectiveness of new innovations that can stimulate changes in the health system through adaptation of research into policy and practice. In the second pathway, “thought leadership,” NGOs disseminate lessons learned to public and private partners through training, information sharing and collaborative learning. In the third pathway, “joint venturing,” NGOs work in partnership with the government health system to demonstrate the efficacy of a project and use their collective voice to help guide decision-makers. In addition to these pathways, we present six key drivers that are critical for successful institutionalization: strategic responsiveness to national health priorities, partnership with policymakers and other stakeholders, community ownership and involvement, monitoring and use of data, diversification of financial resources, and longevity of efforts. With additional research, we propose that this framework can contribute to program planning and policy making of donors, governments, and the NGO community in the institutionalization of community health strategies.

CONTEXT: Although men potentially play an important role in emergency obstetric care in Sub-Saharan Africa, few studies have examined the ways in which men are ...