And the Need for Improved Maternal Water Literacy.

by Dr. Christiaan Morssink 

stunted on the vine © pam lazos

In the late nineties, the World Health Organization undertook a major international study to create a growth chart for children 0-5yrs. ( The WHO was chaired by Cutberto Garza, then professor at Boston College. The study specifically focused on ideal social conditions — stable food security related to high socio-economic status, high levels of education, family life — and ‘ideal” behaviors of mothers (non-smoking, breastfeeding, regular health care check-ups, socially mobile).  The results of the study were striking:  race, continent, religion, and language were unimportant. The charts, composed from the children’s growth in ideal circumstances, were incredibly tight with little variation within countries AND BETWEEN COUNTRIES. The study results led to the adoption of a universal “optimal” infant growth chart.

Many articles have been written since around the methodology, cut off points and how to use these WHO charts, quite a few specifically around the need to compare CDC charts with WHO charts. A renewed focus on breastfeeding as a goal for action for nutrition and health professionals took place. Mother’s milk became First Food. Deviations from the growth curve were tracked around malnutrition (nutrient deficiencies or sheer hunger episodes) and stunting became (again) understood as impacting negatively on physical and mental health as adults. 

Much less attention was given to some other variables that stood out in the selection of well-off mothers who were willing to breastfeed, did not smoke, and could afford to visit health care facilities on schedule or when needed. One of these variables refers to housing conditions. It can be assumed that all the mothers in the study lived in secure housing, with good indoor air quality and with running, piped water, and good toilet facilities.  We can also assume that these mothers had the wherewithal to apply their knowledge to childcare, unencumbered by traditions and/or fashion. Indeed, nutrition involves water, not in the least in that process of weaning the infant from breast feeding to solid foods and practicing good hygiene for mother and child throughout the day. 

There is a good number of (field) studies on the relationship between water, hygiene, and stunting.  

No research was ever found that indicated that poor nutrition, or poor hygiene led to better health outcomes. The research is mostly related to associations between episodes of poor nutrition or poor hygiene and prevalence rates of malnutrition and stunting. And most research uses methods and had operational limitations that rendered strong causality almost impossible. The foremost finding of a systematic review of the literature, published in 2018, was “the low-to very-low quality evidence” as found in the studies reviewed. (Indian Pediatr. 2018 May 15;55(5):381-393. Epub 2018 Feb 9.

photo credit: World Health Organization

Nutrition can be measured in terms of quality and quantity, through time and according to developmental needs. Water, and hygiene are much more difficult to quantify, identify, or analyze in terms of impact on health, including infant health. When is water enough, too much, safe, too safe? When is a latrine safe, and when not? 

The consensus is limited to the insight that good WASH facilities and practices will impact on stunting and malnutrition. It is not so clear whether it will be possible to ever create an optimum WHO WASH CHART. What is clear though, is that to create such a chart, the women of the world will be the major stakeholders, as mothers, as consumers, as professionals, researchers, politicians, business leaders, educators, and “health makers.” 

I invite you to engage.

March is International Women’s Month. Go thank the wonderful women in your life, especially your mother!

Dr. Morssink is the President of the Global Water Alliance and his interests are as varied and flowing as water itself, such as: the effects of the built environment on health, the elimination of health disparities, urban farming to end hunger, and the campaign to ban and clear landmines and cluster bombs in communities around the world. Water is his first love.