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• W1990376162 abstract "To explore linkages between water, sanitation and hygiene (WASH) and maternal and perinatal health via a conceptual approach and a scoping review. We developed a conceptual framework iteratively, amalgamating three literature-based lenses. We then searched literature and identified risk factors potentially linked to maternal and perinatal health. We conducted a systematic scoping review for all chemical and biological WASH risk factors identified using text and MeSH terms, limiting results to systematic reviews or meta-analyses. The remaining 10 complex behavioural associations were not reviewed systematically. The main ways poor WASH could lead to adverse outcomes are via two non-exclusive categories: 1. ‘In-water’ associations: (a) Inorganic contaminants, and (b) ‘water-system’ related infections, (c) ‘water-based’ infections, and (d) ‘water borne’ infections. 2. ‘Behaviour’ associations: (e) Behaviours leading to water-washed infections, (f) Water-related insect-vector infections, and (g-i) Behaviours leading to non-infectious diseases/conditions. We added a gender inequality and a life course lens to the above framework to identify whether WASH affected health of mothers in particular, and acted beyond the immediate effects. This framework led us to identifying 77 risk mechanisms (67 chemical or biological factors and 10 complex behavioural factors) linking WASH to maternal and perinatal health outcomes. WASH affects the risk of adverse maternal and perinatal health outcomes; these exposures are multiple and overlapping and may be distant from the immediate health outcome. Much of the evidence is weak, based on observational studies and anecdotal evidence, with relatively few systematic reviews. New systematic reviews are required to assess the quality of existing evidence more rigorously, and primary research is required to investigate the magnitude of effects of particular WASH exposures on specific maternal and perinatal outcomes. Whilst major gaps exist, the evidence strongly suggests that poor WASH influences maternal and reproductive health outcomes to the extent that it should be considered in global and national strategies. Explorer les associations entre le système ‘eau-assainissement-hygiène’ et la santé maternelle et périnatale par une approche conceptuelle et une analyse de la portée. Nous avons développé un cadre conceptuel itérative, combinant trois filtres sur base de la littérature. Nous avons ensuite recherché dans la littérature et avons identifié les facteurs de risque potentiellement associés à la santé maternelle et périnatale. Nous avons mené une analyse systématique de la portée pour tous les facteurs de risque chimiques et biologiques du système ‘eau-assainissement-hygiène’ identifiés en utilisant des termes de texte et de MeSH, limitant les résultats à des analyses systématiques ou des méta-analyses. Les 10 associations comportementales complexes restantes n'ont pas été analysées systématiquement. Les principales façons par lesquelles un mauvais système ‘eau-assainissement-hygiène’ pourrait conduire à des résultats négatifs se réalisent via deux catégories non exclusives: (A) Associations via ‘l'eau’: (a) contaminants inorganiques, (b) agents infectieux: (i) «basés sur l'eau, ‘(ii) ‘d'origine hydrique’, (iii) ‘liés aux systèmes d'eau’’. (B) Associations liées au ‘comportement’: (c) comportements conduisant à des infections par l'eau, (d) infections par des insectes vecteurs liés à l'eau, (e) comportements conduisant à des maladies/conditions non-infectieuses. Nous avons ajouté des filtres pour l'inégalité entre les genres sexuels et sur le parcours de vie au cadre ci-dessus afin de déterminer si le système ‘eau-assainissement-hygiène’ affectait la santé des mères en particulier et agissait au-delà des effets immédiats. Ce cadre nous a mené à identifier 77 mécanismes de risque (67 facteurs biologiques ou chimiques et 10 facteurs comportementaux complexes) reliant le système ‘eau-assainissement-hygiène’ aux résultats de santé maternelle et périnatale. Le système ‘eau-assainissement-hygiène’ affecte le risque de résultats adverses sur la santé maternelle et périnatale; ces expositions sont multiples et se chevauchent, et peuvent être loin du résultat immédiat de santé. La plupart des preuves sont faibles, basées sur des études observationnelles et des preuves anecdotiques, avec relativement peu d'analyses systématiques. De nouvelles analyses systématiques sont nécessaires pour évaluer de façon plus rigoureuse la qualité des preuves existantes et une recherche primaire est nécessaire pour investiguer sur l'ampleur des effets de certaines expositions au système ‘eau-assainissement-hygiène’ sur des résultats spécifiques de santé maternelle et périnatale. Alors que de graves lacunes existent, l’évidence suggère fortement qu'un mauvais système ‘eau-assainissement-hygiène’ influence les résultats de santé maternelle et reproductive dans la mesure où il doit être pris en compte dans les stratégies nationales et mondiales. Explorar las relaciones entre el agua, el saneamiento y la higiene (ASH) y la salud materna y perinatal mediante un enfoque conceptual y revisión bibliográfica exploratoria Hemos desarrollado un marco conceptual iterativo, amalgamando tres enfoques basados en publicaciones. Después realizamos búsquedas en la literatura e identificamos factores de riesgo potencialmente relacionados con la salud materna y perinatal. Hemos realizado una revisión exploratoria sistemática para todos los factores de riesgo químicos y biológicos del ASH identificados, utilizando términos de texto y MeSH, limitando los resultados a las revisiones sistemáticas o los meta-análisis. Las otras 10 asociaciones complejas de comportamiento no fueron revisadas de forma sistemática. Las principales formas en las que una mala ASH podría conllevar a efectos adversos podían agruparse en dos categorías no excluyentes: (A) Asociaciones ‘en el agua’: (a) contaminantes inorgánicos, (b) agentes infecciosos: (i) ‘basados en el agua’ (ii)’transmitidos por el agua′ (iii) relacionados con ‘sistemas de agua’. (B) Asociaciones relacionadas con el comportamiento: (c) Comportamientos que conllevan a infecciones transmitidas en el agua, (d) Infecciones por insectos-vectores relacionados con el agua, (e) Comportamientos que conllevan a condiciones / enfermedades no infecciosas. A este marco añadimos también inequidad de género y la perspectiva de toda una vida, con el fin de identificar si el ASH afectaba la salud de las madres en particular y actuaba más allá de los efectos inmediatos. Este marco nos permitió identificar 77 mecanismos de riesgo (67 factores químicos o biológicos y 10 factores complejos de comportamiento) que relacionaban al ASH con los resultados en salud materna y perinatal. El ASH afecta el riesgo de resultados adversos en salud materna y perinatal; estas exposiciones son múltiples y se solapan, y podrían ser lejanas al resultado de salud inmediato. Una buena parte de la evidencia es débil, basada en estudios observacionales y evidencias anecdóticas, con relativamente pocas revisiones sistemáticas. Se requieren nuevas revisiones sistemáticas para evaluar la calidad de la evidencia existente de una forma más rigurosa y se necesitan estudios primarios que investiguen la magnitud de los efectos de ciertas exposiciones del ASH sobre resultados específicos a nivel materno y perinatal. Mientras que existen grandes vacíos, la evidencia parece sugerir que una ASH pobre influye sobre los resultados de salud materna y reproductiva, hasta el punto de que deberían tenerse en cuenta en estrategias nacionales y globales. As 2015 draws closer, there is much debate at an international level as to what will follow the Millennium Development Goals (MDGs) (Horton 2012). The unfinished MDG agenda has been discussed and a desire to complete work on current MDGs stated (The United Nations 2012). Yet it has also been argued that the sector-specific goals and targets embodied in the MDGs resulted in missed opportunities in terms of potential implementation synergies (Waage et al. 2010). Elsewhere, the limited progress on reducing the ‘equity gap’ under the MDGs has been raised as a major concern (Chopra et al. 2012). This article focuses directly on the potential synergies and links between improving maternal, newborn and reproductive health and safe water, sanitation and hygiene (WASH) and proposes a conceptual framework for understanding them. The MDG7 target for water and sanitation calls for the ‘halving of the proportion of the population without sustainable access to safe drinking water and basic sanitation’ by 2015 (United Nations General Assembly 2000). The water target was declared as met in 2010, although 780 million people remain without safe water, whilst the sanitation target is seriously off track and unlikely to be met by 2015, with 2.5 billion people still lacking access (UNICEF, WHO 2012). Coverage of these services is lowest in the poorest regions and countries of the world, and most acute among the poorest populations in these settings (UNICEF, WHO 2011). There was no target for hygiene in MDG7, nor it is consistently measured in global or national WASH monitoring systems. Assessments of the disease burden associated with poor WASH are dominated by diarrhoeal disease mortality and acute morbidity (Guerrant et al. 2002). Whilst diarrhoeal mortality is reducing, it still accounts for 10% of all child deaths (Liu et al. 2012) and morbidity has declined only slightly since 1990 (Fischer Walker et al. 2012). There is good evidence for the effect of WASH on a range of other health outcomes, including acute respiratory infections (Rabie & Curtis 2006), soil-transmitted helminth infections (Ziegelbauer et al. 2012) and diseases associated with chemical contamination of water (Fewtrell et al. 2005). Combining multiple health effects, WHO estimates that unsafe WASH is responsible for almost one-tenth of the global disease burden (Prüss-Üstün et al. 2008). To date however, we are unaware of any quantification of the effects of poor WASH on maternal and perinatal health. Under MDG5, target 5a is ‘to reduce maternal mortality by three-quarters by 2015’ (United Nations General Assembly 2000). Influential frameworks for improving maternal mortality – such as the ‘Three Delays’ (Thaddeus & Maine 1994) and the ‘Continuum of Care’ (Partnership for Maternal Newborn & Child Health 2011) models – focus almost exclusively on improving access to, and the quality of, maternal health services, with little focus on the wider social and environmental determinants. This emphasis on health services recurs for the MDG5b targets, which address contraceptive coverage and antenatal care services. In this study, we explore tentative and confirmed linkages between WASH and maternal and perinatal health using scoping review methods and present a conceptual approach for systematically describing these. Our aim is to provide a broad-ranging conceptualisation that may then be used to guide a process of gathering epidemiologic data on the potential impact of the various risk factors on the ill health of mothers and foetuses/newborns. Although beyond the scope of this study, estimating the contribution of these risk factors to ill health at the population level (population attributable fractions) could then form the basis for identifying and harnessing policy, advocacy and programming synergies that will lead to more effective, efficient and equitable investments in both sectors. We end by identifying research gaps, which, if addressed, would strengthen this framework and lead to greater policy coherence and more effective interventions. Miles and Huberman (1994) state that a conceptual framework ‘lays out the key factors, constructs or variables, and presumes relationships among them’. Methods for developing frameworks vary, but ours was developed iteratively, using our experiential knowledge (including our technical knowledge and research background) and our literature review that included previous related theory and research, and concepts that had been used to represent similar problems (Novak & Canas 2008). The aim of the framework was to classify and organise the concepts and emphasise connections between them. Our conceptual framework amalgamated three main perspectives: a gender-based lens focusing on health inequalities (Kirschstein 1991), the classification of WASH-related health outcomes (White et al. 1972) and the longer-term perspective afforded by a life course approach (Kuh et al. 2003; Mishra et al. 2010). We applied these perspectives to information extracted from an exploratory literature review that, whilst not systematic, included electronic searches of PubMed and Google Scholar among others, and manual searching of references within key articles. We also searched all the ‘mode of transmission’ and ‘susceptibility’ headings in the Control of Communicable Disease Manual, 19th edition (Heymann 2008), to assess whether transmission for each infectious disease was WASH-related and whether women (or pregnant women and their foetuses/newborns) were at particular risk. We ended by further refining the framework in the light of this targeted search. Through these searches, we identified 77 potential factors that we categorised within our framework. We followed with a more targeted scoping with the objective of providing an overview of the existing evidence linking the identified 77 exposures to reproductive and maternal health outcomes, whilst recognising evidence gaps (Arksey & O'Malley 2005; Levac et al. 2010). We systematically searched Medline and Embase databases, combining text and MeSH terms for maternal and newborn health among humans with text and MeSH terms for identified 67 chemical and biological mechanisms of exposure. We limited the results of each search to references containing text or MeSH terms for systematic reviews or meta-analyses. We placed no limitations on the date of publication or the language of manuscript. All search results were exported to an EndNote database and screened by one co-author (LB or GG). Systematic reviews that considered the association between any aspect of reproductive or maternal health and the presence or prevention of any of the 67 exposures were identified. The remaining ten behavioural exposures are complex phenomena and would require collaboration with experts from fields beyond public health, such as anthropology, economics and sociology to identify target search terms, databases and grey literature. We did not do a systematic scoping review for these exposures as it was beyond our resources. However, we present individual studies and reports linking reproductive and maternal health to these ten exposures. Webtable S1 presents the complete listing of the 77 identified mechanisms and indicates availability of systematic reviews and other evidence based on our searches. Only the mechanisms for which links (systematic or other) with reproductive and maternal health were identified are presented in Webtable S2, along with a brief summary of the findings. We first present the lens or framework (gender lens, WASH transmission framework and the life course perspective) and then the evidence to support posited effects. Much of the debate in recent decades around the need for epidemiological theory has been in relation to understanding and addressing health inequalities (Krieger & Zierler 1996; Susser & Susser 1996). Our first lens is explicitly gender inequality, although we refer to other inequalities such as poverty or urban/rural divides where they have been described. Both biology and gendered behaviour contribute to differences in men's and women's health (Kirschstein 1991; Weisman 1997). The National Institutes of Health (NIH) distinguishes women's health as diseases or conditions ‘unique to women or some subgroup of women; more prevalent in women; more serious among women or some subgroup of women; for which the risk factors are different for women or some subgroup of women; and for which the interventions are different for women or some subgroup of women’ (Kirschstein 1991). As most WASH-related diseases or conditions affect both men and women, we used this definition to highlight those particularly relevant to women in general and to mothers more specifically. If pregnant women were not particularly susceptible, exposed, or affected, but their exposure to WASH-related hazards affected the foetus or newborn, we also highlighted such effects (Kourtis et al. 2014). Figure 1 summarises the main ways in which water or sanitation or hygiene can plausibly lead to ill health, distress, harmful behaviours or other adverse outcomes, grouped in two main dimensions: (i) ‘in water’ – microorganisms or chemicals in water and (ii) ‘behaviour’ – actions or cultural aspects related to WASH, including aspects relating to the location of the water point or sanitation facility. We sought to understand how WASH affects health in general and where women, pregnant women, foetuses or newborns are particularly affected. The Figure 1 framework builds on the Bradley classification which identified four principal pathways of water-related disease transmission: ‘water-based’, ‘water-borne’, ‘water-washed’ and ‘water-related’ (White et al. 1972). The first two categories are grouped in the ‘in-water’ dimension, which also incorporates subsequent adaptations (Kistemann 2004) to allow for aerosol transmission (Bartram et al. 2007), chemical contaminants (Dar & Khan 2011) and chemicals deliberately added to maintain water systems or as public health measures (Ashbolt 2004). The third and fourth Bradley categories are grouped under our ‘behaviour’ dimension, combining ‘water-washed’ and ‘water-related’ with three more ‘behaviour’ categories related to the hazards of location, distance and perceptions of availability or stigma. Our categorisation is influenced by Cairncross and Feachem's (1993) observation that most faecal–oral infections can be water-washed and that behaviours linked to scarce water, poor sanitation and hygiene can affect these (Wagner & Lanoix 1958). The location and nature of water supply also affects water-related insect vector transmission. For example, wastewater stabilisation ponds can increase mosquito breeding sites (Cairncross & Feachem 1993; Mukhtar et al. 2006). Below, we give evidence for these associations grouped by the two dimensions of ‘in water’ and ‘behaviour’ in the order shown in Figure 1. Webtable S1 presents a detailed list of various transmission routes or mechanisms that may potentially affect health or well-being and summarises the availability of evidence of their impact on women, foetuses or newborns (systematic reviews, other evidence or no evidence). We were able to identify evidence of association for 47 of the 77 identified exposure mechanisms and found at least one systematic review for 30 of the 67 mechanisms for which we conducted a search for systematic reviews. The ‘in-water’ associations relate to two main areas: (i) inorganic contaminants and (ii) infectious agents. Many settings have high naturally occurring levels of arsenic and fluoride in groundwater. Studies have linked exposure to arsenic in drinking water with higher risks of spontaneous abortion (Milton et al. 2005; Rahman et al. 2007), stillbirth (Cherry et al. 2008) and infant mortality (Rahman et al. 2010), and fluoride has been associated with low birthweight (Diouf et al. 2012) and skeletal fluorosis (Bo et al. 2003). It has been estimated that in the coastal areas of Bangladesh, increasing saline intrusion during the dry season results in people consuming 2.5–8 times the recommended salt intake, potentially leading to hypertensive disorders of pregnancy (HDP) (Khan et al. 2011). Industrial contaminants, particularly metals, in drinking water raise concerns for pregnant women, with a systematic review showing adverse effects of metal exposure on placental function and foetal development (Caserta et al. 2013), as well as neurodevelopment and other effects in children (Pocock et al. 1994; Ferris et al. 2008). Exposure to mercury, potassium or lead, for example, is associated with spontaneous abortion (Aschengrau et al. 1989) and congenital malformations (Vahter et al. 2002; Bellinger 2005). Lead is nephrotoxic and can progressively lead to renal failure, gout and hypertension, all risk factors for HDP (Nolan & Shaikh 1992; Ekong et al. 2006). Prenatal exposure resulting in maternal blood lead levels of >10 μg/dl can adversely affect fertility, hypertension, infant neurodevelopment and foetal growth (Bellinger 2005). Systematic reviews of exposure to agricultural pesticides and herbicides – that may be consumed via contaminated surface or groundwater – have shown that whilst there is inconclusive evidence for an association between residential proximity to agricultural pesticides and adverse pregnancy outcomes (Shirangi et al. 2011), systematic reviews of parental exposure to specific pesticides show these to be associated with specific cancers and other adverse outcomes among children (Lopez Duenas et al. 2012; Nicolle-Mir 2012). Some studies have shown that pregnant women and their foetuses are particularly susceptible to effects of nitrates (Calderon 2000), including spontaneous abortions, intrauterine growth restriction, congenital malformations and methaemoglobinaemia (blue baby syndrome), although a systematic review suggests these links are inconclusive (Manassaram et al. 2006). Endocrine-disrupting compounds mimic and/or block effects of endogenous hormones and have been associated with earlier age at menarche in a systematic review (Yermachenko & Dvornyk 2013). Early age at menarche is associated with earlier age at first sex, and earlier pregnancy, which in turn, is associated with worse pregnancy outcomes. Endocrine disrupters have also been linked to altered ovarian function, impaired fertility and changed placental function (Balabanič et al. 2011; Buttke et al. 2012; Fowler et al. 2012) and to a higher risk of spontaneous abortions and low birthweight (Calderon 2000; Balabanič et al. 2011), although systematic review results of these are inconclusive (Peters et al. 2010; Caserta et al. 2011). It is generally agreed that disinfection by-products may potentially cause spontaneous abortions (Waller et al. 1998), stillbirths (King et al. 2000), birth defects (Cedergren et al. 2002) and small-for-gestational-age infants (Grellier et al. 2010). Some of these associations are supported by systematic reviews. The second subgroup within the ‘in-water’ dimension concerns infectious agents in the water, grouped in the additional ‘water-systems’ category and Bradley's ‘water-based’ and ‘water-borne’ categories (Categories C and D in Figure 1). Whilst water systems can spread infection via poorly maintained air-cooling systems and cause Legionnaires’ disease, this is uncommon and affects the general population without posing particular risks to women (Heymann 2008), so are not considered here, although the category is included in Figure 1 for completeness. Water-based infections are transmitted via aquatic vectors, such as snails, fish or crustaceans, in which part of the life cycle of the infective agent occurs. Schistosomiasis is notable from a maternal/reproductive health perspective as genital schistosomiasis is associated with cervical cancer (Feldmeier et al. 1995; Moubayed et al. 1995), ectopic pregnancy and infertility (Swai et al. 2006); and in pregnant women, it is associated with anaemia (Abdelgadir et al. 2012), undernutrition (King et al. 2005) and inflammation (Kurtis et al. 2011). It can also affect foetal immune response (Seydel et al. 2012), leading to foetal inflammation (Kurtis et al. 2011) and low birthweight (Siegrist & Siegrist-Obimpeh 1992; Qunhua et al. 2000). However, there are no systematic reviews. Other water-based infections, such as dracunculiasis (guinea worm) or diphyllobothriasis (tapeworm), are not known to pose specific risks to women, although pregnant or lactating women may be excluded from treatments if drugs had not been tested in pregnant women and are thus contraindicated (Gyapong et al. 2003). Exclusion from treatment because of pregnancy or breastfeeding applies also to other WASH-related diseases and conditions (Maduka et al. 2004). Water-borne infections are directly transmitted by micro-organisms in water, the classic example being cholera. Here, we consider those that differentially affect women, such as Hepatitis E, with higher incidence, greater severity of symptoms and elevated mortality rates among pregnant women (Emerson & Purcell 2004; Heymann 2008; Aggarwal & Naik 2009). It is also associated with a greater risk of stillbirth (Rein et al. 2012). Most water-borne infections are faecal–oral and overlap with the water-washed category and so are captured in the second dimension of ‘behaviour’. This dimension concerns the health effects posed by behaviour relating to WASH. Cairncross and Feachem's redefinition of the water-washed category included infections spread by behaviours stemming from a lack of water or from poor hygiene, including personal and domestic hygiene, and hygiene in the public domain such as in educational establishments and workplaces, including health facilities (Cairncross et al. 1996). There are many examples of water-washed infections. Evidence in this area can be dated at least as far back as the elegant work of Gordon (1795) and Semmelweis (1983) demonstrating the association between puerperal sepsis and poor hygiene of birth attendants, a theory later strengthened by the discovery that the causal agent was Streptococcus A, a water-washed infection. Sepsis in pregnancy or the puerperium is mainly caused by unhygienic practices and poor infection control, including lack of hand-washing, unclean surfaces and unhygienic vaginal examination or cord-cutting in health facilities or in the home (Ali et al. 2006; Darmstadt et al. 2009). Tetanus is another important contributor to mortality of mothers and newborns, and tetanus toxoid vaccination among pregnant women reduces neonatal death and morbidity (Fauveau et al. 1993; Demicheli et al. 2005; Roper et al. 2007; Kourtis et al. 2014). Staphylococcus can be another common cause of puerperal or newborn infection (Heymann 2008). Some intestinal worm infections can also be classified as water-washed. An estimated 6.9 million pregnant women in sub-Saharan Africa are infected with hookworm, and systematic reviews show they are at risk of hookworm-related anaemia (Brooker et al. 2008). Hookworm infestation in pregnancy is associated with decreased infant birthweight and intrauterine growth retardation (Christian et al. 2004), and a systematic review indicated that maternal antihelminthic treatment reduced stillbirths (Menezes et al. 2009). Systematic reviews of ascariasis and trichuriasis showed them to be associated with maternal anaemia (Noronha et al. 2012) and with stunting and cognitive deficits, respectively (Ruma et al. 2008). Helminth infections are also associated with increased susceptibility to HIV/AIDS, malaria and tuberculosis (Fincham et al. 2003; Le Hesran et al. 2004; Elias et al. 2007). Systematic reviews indicated that the most common non-malaria bloodstream infection among pregnant women admitted to hospital in reviews of studies from both Africa (Reddy et al. 2010) and Asia (Deen et al. 2012) is Salmonella enterica, to which pregnant women have greater susceptibility (Smith 1999). Salmonella can result in spontaneous abortion (Smith 1999). Listeria, another water-borne/water-washed infection, has an annual infection rate over 17 times higher among pregnant women (Southwick & Purich 1996), who account for 27% of all listerial infections (Janakiraman 2008). Exposure in pregnancy is associated with spontaneous abortion (Heymann 2008), stillbirth and preterm delivery (Goldenberg & Thompson 2003). The latter association is confirmed in systematic reviews (Lamont et al. 2011; Semedo Leite et al. 2012). A systematic review of neonatal melioidosis suggested that vertical transmission exists (Thatrimontrichai & Maneenil 2012), whilst a systematic review of Yersinia infection showed it to be associated with adverse pregnancy outcomes (Semedo Leite et al. 2012). The only study found by a systematic review of antenatal genital tract screening and treatment for lower genital tract infection (GTI) showed a reduced risk of preterm birth and preterm low birthweight (Xiong et al. 2006). Pregnant women face increased susceptibility to influenza, with increased severity of illness (Jamieson et al. 2006). A systematic review showed higherates of hospitalisation, ICU admission and death among pregnant women during the 2009 A(H1N1) flu pandemic (Mosby et al. 2011). Numerous water-related insect vector infections are transmitted via mosquitoes (malaria, dengue, lymphatic filariasis and yellow fever), tsetse flies (trypanosomiasis) and black flies (onchocerciasis) that live or bite near water. Some of these, namely malaria and dengue, pose specific risks related to women. Pregnant and post-partum women, particularly primi- and secundi-gravidae, are more susceptible to malaria (Boel et al. 2012; Chico et al. 2012), whereas more subclinical presentation obscures detection and treatment (Desai et al. 2007). Malaria in pregnant women is associated with an increased risk of anaemia and severe anaemia (Shulman et al. 2002). An estimated 0.5–23.0% of maternal deaths in high transmission areas and 0.6–12.5% in low transmission areas are caused by malaria (Brabin & Verhoeff 2002). Infection with malaria also increases risk of spontaneous abortion (McGready et al. 2012), stillbirth (Goldenberg & Thompson 2003) and intrauterine growth retardation (Steketee et al. 2001) and leads to anaemia in newborns (van Eijk et al." @default.
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• W1990376162 title "Getting the basic rights – the role of water, sanitation and hygiene in maternal and reproductive health: a conceptual framework" @default.
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