Author: Mahrukh Saleem, Teresa Burdett and Vanessa Heaslip
Affiliated organisation: BMC Public Health
Type of publication : Research article
Date of publication : February 2019
Open defecation is defined as the practice of defecating in open fields, waterways and open trenches without any proper disposal of human excreta. Open defecation is classified as unimproved sanitation. Despite 15 years of conjunctive efforts under global action plans such as the Millennium Development Goals (MDGs), targets for improved sanitation were not met, resulting in 2.5 billion people not having access to improved sanitation facilities (flush latrine or pit latrine) and nearly 892 million of the total world’s population still practising open defecation.
The health risks most researched in the context of open defecation are those associated with infected human excreta that contain several harmful organisms that are associated with a number of health problems. Inappropriate human waste disposal also increases the risk of exposure to these pathogens which can pose significant health risks such as transferable infectious diseases, diarrhea, typhoid and cholera, and viral infections.
Open defecation is an issue that can affect everyone but women are often at more risk of experiencing violence and multiple health vulnerabilities. The interaction between disease and undernutrition can further uphold the vicious cycle of worsening infection and deterioration of women’s health, particularly in pregnant women.
Lack of household toileting facilities forces many women to travel long distances from their house to find private open places to defecate, manage their menstrual necessities which makes them vulnerable to varying forms of violence. Privacy considerations, cultural norms or religious practices also bound many women to wait until dawn or dusk so they would not be seen while fulfilling their basic need of defecating.
Despite 15 years of conjunctive efforts under global action plans such as the Millennium Development Goals (MDGs), targets for improved sanitation were not met, resulting in 2.5 billion people not having access to improved sanitation facilities (flush latrine or pit latrine) and nearly 892 million of the total world’s population still practising open defecation
However, the UN asserts that sanitation has to be considered beyond the scope of just considering health, housing, education, work and gender equality but instead should be considered in terms of human dignity in that open defecation evokes feelings of vulnerability and shame and this infringement to human dignity should be considered a human rights issue.
Health impacts of open defecation
The findings from the review demonstrate plausible evidence that open defecation has a significant impact on the health and well-being of women. Three studies affirm the vulnerability of child-bearing women to open defecation which can be detrimental to both mother and the developing foetus.
Risk of maternal complications increases with poor sanitation as it exacerbates the impacts of poor nutrition due to faecal-oral transmission of infections in pregnant women. A study validates that older girls (over 12 years) were more likely to be infected with soil-transmitted helminths than younger girls.
Increased risk of sexual violence
Two studies focused on assessing the risk of non-partner sexual violence in relation to open defectation, another one highlighted the experiences of sexual assaults and fear related to sexual violence among women after they leave their houses to defecate in open fields or near surroundings. Likewise, a study analysing cross-sectional data from the 2008–09 Kenya Demographic and Health Survey (DHS) identified that the risk of non-partner sexual violence increased to 40% among women who practiced open defecation than women who had the access to toilet facility (either in their household or shared toilet).
Psychosocial stressors linked to open defecation
The most emphasised stressors were: searching for appropriate sites to defecate, travelling long distances, carrying water for cleaning, increased risk of insect or snake bites, fear of ghosts in dark and uncleanliness at site. They also illustrated that women preferred to travel in groups or accompanied by a relative when they need to defecate in open as a mitigating method because of the fear of being verbally, physically or sexually abused which were commonly reported by women who practiced open defection.
The impact is relatively severe for girls and women of reproductive age as they face an additional challenge of managing their menstruation while tackling the everyday need to defecation, however, the issue extend beyond young age and is significant throughout all life stages of women and it is imperative to acknowledge that the involvement of women in designing and placement of toilets stand the best chance of long-term success of reducing sanitation related psycho-social stressors among women.
The overarching themes emerged across the findings clearly present the daunting situation of poor sanitation in rural communities of Lower-Middle Income Countries. The findings also identified that open defecation promotes poor health in women and has long-term negative effects on their psychosocial well-being.
All the health studies included in this review investigated open defecation under the umbrella of poor sanitation. Therefore, this review cannot present a strong conclusion regarding the association between open defecation and women’s health; however, it can be deduced that adverse effects on women’s health attributable to open defecation are significant and in-appropriate human waste disposal increases the risk of contact to the infectious agents and likely to exacerbate exposure to health risks such as infectious diseases.
The impact is relatively severe for girls and women of reproductive age as they face an additional challenge of managing their menstruation while tackling the everyday need to defecation, however, the issue extend beyond young age and is significant throughout all life stages of women and it is imperative to acknowledge that the involvement of women in designing and placement of toilets stand the best chance of long-term success of reducing sanitation related psycho-social stressors among women
Women and girls are often disadvantaged because of different sociocultural and economic aspects that deny them equal rights with men. Not only do they have different physical requirements from men but they also have an additional need for privacy and safety when it comes to their personal sanitation.
The practice of open defecation poses serious health impacts and concern to women’s dignity when it transpires in densely populated areas, especially in rural communities with sanitation
challenges. The problem of open defecation largely persists in low and middle income countries, where lack of resources and limited national budget towards sanitation interventions can obstruct the path to provide adequate sanitation facilities to the entire population. Not only the unfortunate situation of no access to toilets for women is the infringement of basic human rights but it is also an indication of failure of the health and social care authorities who are accountable for ensuring adequate provision of fundamental sanitation facilities.
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