Systematic review and meta-analysis: association between water and sanitation environment and maternal mortality

Trop Med Int Health. 2014 Apr;19(4):368-87. doi: 10.1111/tmi.12275. Epub 2014 Feb 10.


Objective: To assess whether the lack of water or the lack of sanitation facilities in either the home or in health facilities is associated with an increased risk of maternal mortality and to quantify the effect sizes.

Methods: Systematic review of published literature in Medline, Embase, Popline and Africa Wide EBSCO 1980.

Results: Fourteen articles were found. Four of five ecological studies that considered sanitation found that poor sanitation was associated with higher maternal mortality. Meta-analysis of adjusted estimates in individual-level studies indicated that women in households with poor sanitation had 3.07 (95% CI 1.72-5.49) higher odds of maternal mortality. Four of six ecological studies assessing water environment found that poor water environment was associated with higher maternal mortality. The only individual-level study looking at the adjusted effect of water showed a significant association with maternal mortality (OR = 1.50, 95% CI 1.10-2.10). Two ecological and one facility-based study found an association between a combined measure of water and sanitation environment and maternal mortality.

Conclusions: There is evidence of association between sanitation and maternal mortality and between water and maternal mortality. Both associations are of substantial magnitude and are maintained after adjusting for confounders. However, these conclusions are based on a very small number of studies, few of which set out to examine sanitation or water as risk factors, and only some of which adjusted for potential confounders. Nevertheless, there are plausible pathways through which such associations may operate.

Keywords: Africa; effect size; maternal mortality; sanitation; systematic review; water.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Africa / epidemiology
  • Databases, Bibliographic
  • Female
  • Humans
  • Maternal Mortality*
  • Obstetric Labor Complications / microbiology
  • Obstetric Labor Complications / mortality
  • Pregnancy
  • Pregnancy Complications, Infectious / etiology
  • Pregnancy Complications, Infectious / microbiology
  • Pregnancy Complications, Infectious / mortality*
  • Sanitation / statistics & numerical data*
  • Sepsis / complications
  • Sepsis / etiology
  • Sepsis / mortality*
  • Sewage / adverse effects
  • Sewage / microbiology
  • Water Microbiology
  • Water Pollutants / adverse effects
  • Water Supply / statistics & numerical data*


  • Sewage
  • Water Pollutants