The document discusses BabyWASH, an integrated approach to improving water, sanitation, hygiene, nutrition, maternal and child health, and early childhood development for mothers and children under two years old. BabyWASH aims to address the evidence that poor WASH conditions impact health outcomes. The document provides examples of how poor WASH in healthcare facilities increases risks for mothers and babies. It also discusses evidence that many young children live in environments with widespread fecal contamination and identifies the most influential exposure pathways. The BabyWASH Coalition works to increase integration across sectors to improve child well-being in the first 1000 days of life.

1. 1
BabyWASH
IntegratingWASH, Nutrition, MNCH and ECD to Reach
Mothers and Children UnderTwo

2. 2
What is BabyWASH?
BabyWASH is the idea that an integrated approach is better than a
siloed approach for children in the first 1,000 days of life.
• Water, Sanitation and Hygiene (WASH)
• Maternal, Newborn and Child Health (MNCH)
• Nutrition
• Early Childhood Development (ECD)

3. 3
What is the Evidence?
A 2015WHO/UNICEF1 report illustrates the poor
water and sanitation conditions in many health
facilities and makes the case that an increased focus
on WASH is needed to decrease maternal and
newborn mortality rates
A 2014 study4 showed that only a fraction of births take place
in a water and sanitation safe environment, and therefore an
increased focus on WASH is needed to improve MNCH

4. A 2014 study exploring environmental enteric dysfunction (EED)3 raises
the red flag to integrate programming more in the first 3 years, The
authors “advocate for a more holistic view ofWASH oriented to babies
in the first years of life and for the development of interventions
targeted to this age group.”
4
What is the Evidence?
The sanitation hygiene infant nutrition efficacy (SHINE)
trials in Zimbabwe are exploring the ideas that poor
environmental sanitation coupled with infant hand-to-
mouth activity can lead to environmental enteric
dysfunction (EED) and may be a large contributor to
malnutrition and stunting. Therefore,WASH and ECD
interventions are needed in the nutrition sector.

5. Coverage of WASH in Healthcare
Facilities
• 38% do not have an improved water source within
500 meters.
• 35% do not have water and soap for handwashing.
• 19% do not have improved sanitation.
• 42% do not have adequate systems for safe
disposal of healthcare waste.
Source: WHO “Water, Sanitation, and Hygiene in Health Care Facilities:
Status in low- and middle-income countries and way forward.” 2015
Photo Credit: washinhcf.org

6. Quality of Care andWASH
• Lack of WASH services compromises the ability to
provide basic services, such as safe childbirth and
surgery, and prevent hospital acquired infections.
Photos courtesy of Dr. Jenny Foster.

7. Impact of WASH in Healthcare Facilities
on Moms and Babies
7
New mother washes 2 day old infant (a
twin) with bottled water in a facility
with no water source (Uganda)
• Poor WASH and IPC not only increases the
treatment-related risks to mothers, babies, and
health care providers, but also impacts
patients’ satisfaction.
• Evidence of increased maternal mortality
associated with unhygienic water and
sanitation conditions during labor and delivery
(Cheng et al., 2012, Benova et al., 2014)
• Basic and simple hygiene practices during
antenatal care, labor, and birth, such as hand
washing and clean birthing surfaces, can
reduce the risk of infections, sepsis, and death
for infants and mothers by up to 25%.
• Safe WASH is particularly important during
the management of complications, such as
caesarean or preterm delivery.

8. WASH and Healthcare-Associated
Infections among mothers and neonates
• Worldwide, millions of preventable infections- including neonatal
infections- occur every year within the healthcare environment
because of inadequate attention to WASH (GLASS Report, 2012)
• Hospital-born babies in developing countries have reported rates
of neonatal infections 3–20 times higher than those reported for
hospital-born babies in industrialized countries (Zaidi et al., Lancet, 2005)

9. WASH and Healthcare-Associated
Infections among mothers and neonates
• WHO estimates that infections acquired from healthcare
facilities cause up to 56% of all neonatal deaths among babies
born in healthcare facilities in developing countries, 75% of these
occur in SE Asia and sub-Saharan Africa (WHO, 2011)
• Most common causes of
HAIs in neonates in low-
income countries are
enteric bacteria –
probably due to fecal
contamination of the
environment, followed
by Staph aureus – due
to unwashed hands (Zaidi
et al., 2005)

10. BabyWASH at home:
young Children’s
exposure to fecal
contamination in low-
income urban
environments

11. Multiple fecal exposure routes with different risks
Which exposures pose the greatest risk?
Open drains
Sediment Water
Surface Waters
Bathing Laundry
Swimming
Latrines
Surfaces
Food
Ready-to-eat food contaminated by
food handler
Wastewater-irrigated produce
Household
Surfaces
Soil
Objects
Stored drinking
water
Flood zones
Soil Water
Municipal Water
Drinking Bathing
Soil
?

12. Methods
• In Accra, Ghana over 13 month period
• Collected over 1,800 environmental samples (water, soil, food,
surfaces, etc.) tested for indicators of fecal contamination
• Conducted over 500 hours of structured observation of behaviors of
young children
• Duration, frequency, sequence of exposure behaviors
• Data analyzed to estimate relative risks by pathway and place
Analyzing environmental samples
to quantify E. coli
Conducing structured
observations at households

13. Activities and Locations of Children < 5 years (%
observation time), Accra, Ghana 2012-2013
Pavement
29%
Off Floor 40%
On dirt 26% Defecating
7%
Bathing
8%
Eating
33%
Playing 42%
Napping
4%
Stagnant water/
trash area 4%
Drains 2%
Handwashing
5%
156 children
>500 hours observation
• Frequent mouthing of objects
& hands
• Children put objects in mouth
median 4 times per hour
(ranges from 1 to 7 objects
per hour)

14. Risks forYoung Children (2-5 yrs) vary by Pathway
and Neighborhood
Alajo Shiabu
Total risk in
Shiabu was
higher than
Alajo
In both neighborhoods,
the greatest risk of
exposure to fecal
contamination was
through food.
Surfaces
Surfaces

15. Widespread fecal contamination in environment of
young children
• Fecal contamination in the
public domain mainly enters
the domain of young children
through the food supply and
contact with open drains and
soil.
• High fecal contamination in the
domestic environment - floors
and surfaces had equally high
contamination

16. Implications: BabyWASH in healthcare
facility and home
• Poor WASH conditions from birth through the first years of life
can have severe and lasting impact on health
• Improving WASH conditions in healthcare facilities is critical for
safe childbirth and for reducing neonatal morbidity and
mortality
• Many children live in highly contaminated environments.
• Identifying the most influential exposure pathway(s) can
help prioritize the interventions that effectively reduce
health risks to young children from poor WASH

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BabyWASHTarget Areas
WASH
• WASH in health
care facilities
• Clean hands at key
times
• Access to
adequate, safe
drinking water
supply
• Consistent,
sanitary toilet
usage & proper
disposal of faeces
(children &
animals)
• Personal and
household
• hygiene practices
ECD
• Protected, safe
and sanitary
baby/child-friendly
spaces for
exploration and
play
• Hygiene for
baby/child (regular
bathing,
handwashing,
sanitary play and
mouthing/teething
objects)
• Clean and
protected eating
spaces for babies
and young children
MNCH
• Clean births
• Skilled birth
attendants
• Hygienic maternal
self-care
• Resources in place
for clean, rapid
emergency
response
• Appropriate
communication
with mothers,
birth companions
and families
• Comprehensive
essential newborn
care
Nutrition
• Exclusive
breastfeeding <6
months
• Hygienic
complementary
feeding >6 months
• Safe food handling
and protected
eating spaces
• Treated drinking
water >6 months
• Freshly cooked,
diverse, and
nutritious foods

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Potential Benefits
• Save 31,000 mothers and 420,000 babies each year through
more hygienic birth practices. (WHO 2014)
• Reduce the 45% of child deaths each year linked to
malnutrition. (WHO 2016)
• Reduce the 50% of malnutrition associated with unsafe
water, inadequate sanitation, or insufficient hygiene. (WHO
2008)
• Reduce diarrhoea rates by 30-40% through proven hygiene
practices. (WHO 2014)
• Reduce risk of neonatal mortality by 44% by early initiation
of breastfeeding. (Lancet 2014)

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The BabyWASH Coalition
The BabyWASH Coalition is a group of
organisations focused on increasing integration
between the water sanitation and hygiene
(WASH), early childhood development (ECD),
nutrition, and maternal newborn and child
health (MNCH) sectors to improve child well-
being in the first 1000 days.

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What are the Barriers to Integration?
1. Policy barriers - highly siloed policy and institutional structure at all levels
2. Aid architecture - majority of health aid is earmarked for a specific sector
3. Institutional barriers - lack of common objectives and 'language' across
different sectors because of siloed way of working
4. Attitudinal barriers - people used to 'business as usual' and threatened
by change
5. Capacity barriers - both in terms of skills as well as human resources
overall
6. Evidence - lack of robust evaluations of large-scale integrated/inter-
sectoral programmes

21. 21
Supporting Current Initiatives

22. Proposed Sustainable Development Goals Include
Targets for basic WASH in Healthcare Facilities
(Goal 6)

23. Impact of WASH in Healthcare Facilities
on Moms and Babies
• Low coverage and limited quality data on status of WASH in
healthcare facilities
• Lack of WASH services compromises the ability to provide
basic services, such as safe childbirth and newborn care
23
Photo credit: washinhcf.org

24. Objective
The adoption Goal 6 of the SDGs necessitates better and more
comprehensive tools to assess WASH conditions in healthcare
facilities and facilitate evidence-based solutions.
To meet this need, the Center for Global Safe WASH at
Emory University developed the WASH in HCF Scorecard
to assess WASH conditions, infrastructure, and resources
in HCF

25. Scorecard Indicators
WHO Core Indicators for WASH in Healthcare Facilities:
• Water Supply
• Access and Source
• Quality
• Quantity
• Cleaning Routines
• Cleaning practices
• Information and policy
• Equipment and Supplies
• Sanitation Facilities
• Access
• Quality
• Quantity
• Handwashing Facilities
• Waste Management
– Segregation
– Disposal

26. To develop the tool, we drew from and adapted survey
questions from the following guidelines, tools, and
monitoring mechanisms:
WASH in HCF
Scorecard

27. Methods
The tool employs three
methods of data
collection
• Surveys
• Facility observation
checklists
• Water sampling
The assessment takes
approximately 2-3 hours
per site with 1-2
enumerators Tool is administered on a mobile
device
Piloting observation checklist

28. Methods
The tool divided into five sections:
1. Survey with the healthcare facility director
2. Background data collection form (number of patients,
deliveries, etc.)
3. Ward Observation Checklist
4. Toilet Observation Checklist
5. Water Quality Testing (1 water sample per ward)

29. Traffic Light Criteria
Achieved
(Score 3)
Hospital has achieved basic WASH indicators
Opportunity for Improvement
(Score 2)
Hospital has made some progress toward achieving basic
WASH indicators
Attention Required
(Score 1)
Hospital has made little or no progress toward achieving
basic WASH indicators
“Traffic Light” WASH in Healthcare Facility
Scorecard
• Based on the responses to the questions, a data dashboard
calculates a traffic light score for each of the 5 core areas for
WASH in HCF
• Rapid way to show and track progress toward achieving basic
WASH in HCF

30. Domain Score (1-3)
Water Supply 1.7
Source and Access 2.1
Quantity 1.4
Quality 1.6
Sanitation Facilities 2.6
Access 2.6
Quantity 3.0
Quality 2.1
Cleaning Routines 1.8
Equipment and Supplies 2.0
Cleaning Practices 1.5
Information and Policy 1.8
Handwashing Facilities 2.8
Solid Waste Management 2.0
Segregation 3.0
Disposal 1.0
Overall 2.2
Example Data Dashboard for Hospital X
Traffic Light Scoring
Legend
Red 1.0- 1.8
Yellow 1.9 - 2.7
Green 2.8-3.0

31. 1.0 1.2 2.0 3.01.4 1.6 1.8 2.2 2.4 2.82.6
1.0 1.2 2.0 3.01.4 1.6 1.8 2.2 2.4 2.82.6
Water
Supply
Sanitation
Facilities
Handwashing
Facilities
1.0 1.2 2.0 3.01.4 1.6 1.8 2.2 2.4 2.82.6
Cleaning
Routines
Waste
Management
Overall
Score 2.4
1.0 1.2 2.0 3.01.4 1.6 1.8 2.2 2.4 2.82.6
1.0 1.2 2.0 3.01.4 1.6 1.8 2.2 2.4 2.82.6

32. Track a healthcare facility’s progress
toward achieving indicators in a given
area…
1.0 1.2 2.0 3.01.4 1.6 1.8 2.2 2.4 2.82.6
1.0 1.2 2.0 3.01.4 1.6 1.8 2.2 2.4 2.82.6
Water
Supply
2016
Water
Supply
2017

33. 33
1.0 1.2 2.0 3.01.4 1.6 1.8 2.2 2.4 2.82.6
1.0 1.2 2.0 3.01.4 1.6 1.8 2.2 2.4 2.82.6
Water
Supply
Hospital A
Water
Supply
Hospital B
Compare healthcare facilities in a given
area…

34. Compare HCF within a country or
region…

35. WorldVision and Emory University
Partnership
35
Tool grounded in existing
guidelines and evidence
with automated analysis
Vast global network and eager to
apply the tool to facilitate evidence-
based solutions for WASH in HCF

36. WorldVision and Emory University
Partnership
Objectives:
1. Develop a comprehensive overview of the status of
WASH conditions in HCF in regions where World
Vision works
2. Use these data to inform and prioritize
programmatic activities to improve WASH in HCF
3. Contribute to the evidence base for advocacy and
action in the area of WASH in HCF
36

37. WorldVision and Emory University
Collaboration in Zambia
• In May-June 2016, data will be collected in 55 HCF
ranging from rural health posts to district hospital
• Assessment will provide some of the first compressive
data on WASH conditions in HCF in Zambia including
water quality data and data on the extent to which
universal access to basicWASH in HCF is met
• After initial assessment,
– jointly review the results
– dissemination to relevant government and development
partners
– develop plans for improvement and scale-up
37

38. Strengths and Limitations
38
Strengths
• Systematic and Flexible: Easy to use and can be employed in various
levels of healthcare facilities and across different country contexts.
• Rapid: Takes ½ day with two enumerators to administer.
• Fills a Gap: Provides much needed data for advocacy and action.
Limitations
• Tool covers a variety of topics, but does not delve deeply into any one topic.
• Tool does not include information on behavior or knowledge, attitudes, and
practices. Focuses on infrastructure, access, and resources.
• Survey component relies on information from the director which could be
inaccurate or subject to biases.

39. • Identify priority areas for
improvement
• Compare conditions across
and within regions to
understand which
problems are widespread
vs. localized
• Track progress over time
39
Implications:
Photo Credit: washinhcf.org
WASH in HCF Scorecard data can be used to:

40. • Data further contribute to the
evidence base for advocacy
and action in the areas of
WASH, healthcare facilities,
and improving health
outcomes for moms and
babies.
Implications:
Photo Credit: washinhcf.org
• Data describes the status of WASH in healthcare facilities
and can help to drive investment in WASH facilities.

41. 41
How is the Coalition Organised?
Members of CoP
Associate Coalition
Members
Core Coalition
Members
• Attend monthly meetings
• Share relevant learnings
from organisation
• Not a member of a particular
workstream but review products
and provide feedback
• Willing to help pilot or take part
in coalition activities
• Part of at least one
workstream
• Gather feedback and pilot
programs

42. Participation to Date
42

43. 43
Coalition Workstreams
Programme
Implementation
Integration
Metrics
Advocacy

44. 44
WV’s BabyWASHToolkit
Understanding
the Evidence
Base
Designing an
Integrated
Approach
Monitoring and
Evaluation
Policy,Advocacy
& Resource
Acquisition
Future Steps

45. 45
Next Steps
1) Official sign-ups for workstreams
A)Point person for each organisation
B) Co-leads to direct each workstream
2) Initial meeting of each workstream to talk through timeline and
products to be developed
3) Official launch of Coalition at UNGA
1) Announce EWEC commitment and key products we are
working on

46. 46
Questions
• What other gaps do you see?
• How to improve?

47. Discussion Questions
• What types of groups would be interested in using
the WASH in HCF Scorecard?
• How could data from the WASH in HCF Scorecard
be used by government and development partners?
• What are barriers to use of theWASH in HCF
Scorecard?
• Where are the gaps? What should be improved?
47

48. 48
Join Us!
For more information and to join a workstream, e-mail:
admin@babywashcoalition.org
To continue the conversation, join us for aWebEx on June 1st. See our website
for more details: babywashcoalition.org