What is it about?
Many pregnant women in low- and middle-income countries still lack safe water, sanitation and hygiene (WASH). We used data from the PRECISE cohort of over 5,000 pregnant women in The Gambia, Kenya and Mozambique to understand whether WASH is associated with pre-eclampsia, a baby born small for gestational age, or a stillbirth. Women without piped water at home, or with toilets that did not safely separate people from human waste, were at higher risk of these placenta-related complications.
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Why is it important?
Pre-eclampsia, babies born small for gestational age, and stillbirth can involve problems with the placenta. Together, these placenta-related complications contribute to approximately 46,000 maternal deaths and 2.5 million stillbirths and newborn and infant deaths each year, almost all in low- and middle-income countries. Yet many women in these settings still lack access to safe WASH. This raises the question: is unsafe household WASH linked to placenta-related complications? We examined this question in the PRECISE cohort of pregnant women across The Gambia, Kenya and Mozambique. Women using unimproved water sources not protected from outside contamination, such as unprotected wells or springs, had a 23% higher risk of placenta-related complications than women with water piped into their home or yard. Even women using other “improved” sources, generally considered safer, such as public taps or boreholes, had an 18% higher risk. This suggests that where water is collected may matter, not just the source type. Collecting water away from home often means carrying and storing it, which can introduce contamination, and the physical strain and heat involved may also play a part. Women with unimproved sanitation, meaning facilities that do not safely separate people from human waste, such as a pit latrine without a slab or a bucket latrine, had a 15% higher risk than those with improved sanitation. These are associations rather than proof of cause and effect, but they point to WASH as an important and under-researched part of maternal and newborn health. Intervention studies are now needed to test whether bringing safe water and sanitation into households can reduce these complications.
Perspectives
My work to date has mostly focused on how water, sanitation and hygiene (WASH) affect enteric infections, diarrhoea and child nutrition, so this was a new and exciting area for me. Writing this article and collaborating with such an amazing group of researchers from the PRECISE Network has shown me how much we still don’t know about how unsafe household WASH may increase the risk of placenta-related complications in women and the risks this poses for their babies. This gap matters even more because many women in low- and middle-income countries, including many in this cohort, live with these conditions every day. I hope this research encourages researchers, health programmes and policymakers to see WASH as an important part of maternal health, and to support community-centred intervention studies that test whether bringing safe water and sanitation into households can reduce these complications. I would like to thank the women and families who took part, and my colleagues in the PRECISE Network for the opportunity to collaborate on this work. I hope it contributes to a future where no woman faces an avoidable risk of pregnancy complications because of where she lives.
Joseph Wells
London School of Hygiene & Tropical Medicine
Read the Original
This page is a summary of: Evaluating the association between household water, sanitation and hygiene (WASH) and selected placenta-related complications in The Gambia, Kenya and Mozambique, PLOS Global Public Health, October 2026, PLOS,
DOI: 10.1371/journal.pgph.0005004.
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