Many low- and middle-income countries still depend on paper-based maternal and child health records that are frequently incomplete, fragmented and difficult to use for continuity of care and clinical decision-making. SPT is designed to bridge this gap: it retains the familiar paper forms that clinicians already use, but adds a digital layer in which completed documents are scanned and captured into an electronic system. The study team, guided by Rapid Assessment Procedures, evaluated the early implementation of the technology through 30 semi-structured interviews, four focus group discussions involving 30 participants, and non-participant observations across key service delivery areas. Participants included facility-level clinical, management and administrative staff, Ministry of Health personnel, and technical and implementing partners. The data were analysed thematically using NVivo 14.

Respondents identified several concrete advantages. Because SPT built on existing paper-based workflows, staff did not need to abandon routines they knew well, and the participatory introduction process reinforced this sense of continuity. Health workers also reported benefits in reporting, in retrieving patient information, and in linking maternal and infant records, a longstanding weakness of fragmented paper systems that can disrupt care across pregnancy, birth and infancy.

These gains, however, proved contingent on the surrounding implementation context. The study documented uneven training coverage among staff, periods of dual documentation in which paper and digital records had to be maintained in parallel, limited internet connectivity, scanning and data capture errors, storage constraints, and concerns about data governance. Rather than abandoning the system, staff responded with peer mentoring, remote troubleshooting and local workarounds, indicating a degree of organisational resilience that the authors note as important for early adoption.

Participants emphasised that successful scale-up would depend on sustained training, clear governance arrangements, adequate human and technical resources, and a phased transition towards government ownership. The researchers conclude that SPT offers a practical pathway towards digitisation in maternal and infant health services in low- and middle-income countries, but that its success hinges on strong organisational systems, workforce support and implementation processes responsive to the realities of routine service delivery. As a qualitative descriptive evaluation of two pilot facilities, the study captures early implementation experience rather than measuring clinical outcomes, and the authors frame their findings as evidence on feasibility and acceptability during the initial phase of deployment.

Subject of Research: Early implementation of Smart Paper Technology for maternal and newborn health records in The Gambia

Article Title: Smart Paper Technology for maternal and newborn health data in The Gambia: A qualitative study of early implementation

Article References: Nkereuwem, O., Prauseová, J., Ford, R., Jallow, A. O., Marena, M., Jarju, G., Fofana, S., Cham, M., Manjang, B., Kampmann, B., & Busza, J. (2026). Smart Paper Technology for maternal and newborn health data in The Gambia: A qualitative study of early implementation. PLOS Global Public Health, 6(10), e0006244. https://doi.org/10.1371/journal.pgph.0006244

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0006244

Keywords: Smart Paper Technology, The Gambia, maternal health, newborn health, health records, digitisation, implementation science, qualitative research, low- and middle-income countries, health information systems, Smart, Paper

The research, published in PLOS Global Public Health, drew on data from PRECISE, a prospective observational cohort that enrolled 5,745 unselected pregnant women in The Gambia, Kenya and Mozambique. Unlike many studies that focus on women already attending specialist clinics, PRECISE recruited participants from the general population, giving researchers a picture of pregnancy complications across ordinary communities. The team, led by Joseph Wells and colleagues spanning institutions in all three countries and the United Kingdom, asked a deceptively simple question: are household water, sanitation and hygiene conditions associated with placenta-related complications?

The complications examined were pre-eclampsia, small-for-gestational-age birth, in which the fetus grows more slowly than expected, and stillbirth. These outcomes are connected by a common thread of impaired placental function. Restricted blood flow through the placenta can starve the fetus of oxygen and nutrients, producing growth restriction, and in severe cases fetal death. Pre-eclampsia, meanwhile, arises when the placenta fails to remodel the maternal blood vessels that should supply it, setting off a cascade of maternal hypertension and organ damage. What all three share is a placenta under stress, and the study set out to test whether the household environment might be part of that stress.

To measure exposure, the researchers classified each household’s water source and toilet facility using standard improved and unimproved categories familiar from global monitoring programs. Water piped directly into a dwelling or plot represented the best case, while other improved sources such as public taps or protected wells, and unimproved sources such as unprotected wells or surface water, represented progressively riskier situations. Sanitation was similarly graded from improved facilities to unimproved ones. The analysis then used multivariable modified Poisson regression with robust standard errors, a statistical approach well suited to estimating relative risks for common binary outcomes, adjusting for a panel of potential confounders. Missing exposure and covariate data were low, under five percent, and were handled with multiple imputation to reduce bias.

The results were striking in their consistency. Compared with women whose homes had water piped into the dwelling or plot, those relying on other improved water sources had an eighteen percent higher risk of experiencing any of the selected placenta-related complications, with an adjusted relative risk of 1.18 and a 95 percent confidence interval of 1.07 to 1.31, a finding that was statistically significant at p equals 0.002. Women using unimproved water sources fared even worse, with an adjusted relative risk of 1.23, a confidence interval of 1.00 to 1.50, and a p value of 0.049, just crossing the conventional threshold of significance. Unimproved sanitation told a similar story: relative to improved facilities, unimproved toilets were associated with a fifteen percent increase in risk, with an adjusted relative risk of 1.15, a confidence interval of 1.02 to 1.30, and a p value of 0.019.

What makes these numbers particularly interesting is the pattern within them. The risk was elevated not only for unimproved water but also for improved sources that fall short of piped supply. This points to a subtler mechanism than simple access. Water from a protected well or communal tap may still become contaminated during collection, transport and storage in the home, the stages of the water journey that occur after the source itself. Each transfer is an opportunity for enteric pathogens to enter, and the physical burden of hauling water, often over considerable distances and in repeated trips, adds its own strain on pregnant bodies. The authors suggest that household WASH conditions may influence placental health through both direct and indirect pathways, and the data are consistent with that interpretation.

The direct pathway runs through infection. Unsafe sanitation increases exposure to fecal pathogens, and gastrointestinal infections during pregnancy are not merely uncomfortable. Enteric inflammation can drive systemic immune activation, and mounting evidence from other settings links maternal infection and inflammation to placental dysfunction, altered fetal growth and adverse birth outcomes. Repeated low-grade exposures, the kind that come from chronically contaminated water rather than a single dramatic illness, may be particularly insidious because they never announce themselves as a clinical event. The indirect pathway operates through the sheer physical labor of water collection, which falls disproportionately on women and can intensify during pregnancy when energy demands are already elevated.

Pre-eclampsia adds another layer of biological plausibility to the WASH connection. The disorder is increasingly understood as involving abnormal immune responses and endothelial dysfunction, processes that environmental exposures can influence. Some researchers have proposed that repeated exposure to enteric pathogens and the chronic inflammatory state they induce could interact with the immunological adaptations of pregnancy, potentially contributing to the failed placental vascular remodeling that underlies pre-eclampsia. The current study was not designed to test mechanisms, and its observational design means the associations it reports cannot be read as proof of causation, but the consistency of the water and sanitation findings across exposure types lends weight to the hypothesis that the household environment matters.

The implications for policy are potentially significant. If household WASH conditions genuinely contribute to placenta-related complications, then targeted WASH interventions, from extending piped water supplies to improving household water treatment and storage practices and expanding access to improved sanitation, could become part of the toolkit for reducing maternal and perinatal mortality in low- and middle-income countries. Such interventions would complement existing clinical strategies rather than replace them, but they address a root exposure that clinical care alone cannot touch. The authors argue that these interventions warrant investigation as a potential strategy to improve maternal and neonatal health outcomes, and the scale of the population affected means even modest risk reductions could translate into substantial public health gains.

Future research faces two clear tasks. The first is mechanistic: understanding precisely how water contamination, sanitation-related infection and the physical demands of water collection translate into placental pathology, whether through inflammation, nutritional stress, hypertension or other pathways. The second is interventional: testing whether comprehensive WASH improvements actually reduce the incidence of pre-eclampsia, small-for-gestational-age birth and stillbirth in affected communities. The PRECISE cohort, with its large size and its coverage of three distinct African settings, provides a foundation for both lines of inquiry. For now, the study adds a new dimension to a familiar message: the health of a pregnancy is shaped not only by what happens in clinics and hospitals, but by the water that flows, or fails to flow, into the home.

Subject of Research: The association between household water, sanitation and hygiene conditions and placenta-related pregnancy complications in sub-Saharan Africa

Article Title: Evaluating the association between household water, sanitation and hygiene (WASH) and selected placenta-related complications in The Gambia, Kenya and Mozambique

Article References: Wells, J., Waiswa, J., Vala, A., Golla, B., Mwashigadi, G., Jah, H., Temmerman, M., Okello, R., Mwaniki, I., Cossa, H., Mukhanya, M., Sevene, E., Idris, Y., Wanje, O., Koech, A., Roca, A., Braun, L., Volvert, M.-L., Touray, F., … the PRECISE and PRECISE-DYAD Networks (2026). Evaluating the association between household water, sanitation and hygiene (WASH) and selected placenta-related complications in The Gambia, Kenya and Mozambique. PLOS Global Public Health, 6(10), e0005004. https://doi.org/10.1371/journal.pgph.0005004

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0005004

Keywords: WASH, placenta, pre-eclampsia, small-for-gestational-age, stillbirth, maternal health, The Gambia, Kenya, Mozambique, water contamination, sanitation, PRECISE cohort

The study, published in Environmental Advances, drew on electronic health records from the Medical Research Council Unit The Gambia clinic in Keneba, a facility that has provided free healthcare to residents of the surrounding West Kiang region for decades. Between January 2010 and December 2022, the clinic recorded 11,331 visits for diarrheal diseases and 29,420 visits for skin infections. Roughly seven in ten diarrheal visits involved children under five, while skin infections were more evenly distributed across age groups. The researchers aggregated these visits into weekly counts and matched them against weekly rainfall and temperature data from the European Centre for Medium-Range Weather Forecasts ERA5-Land reanalysis dataset, extracted at roughly ten kilometre resolution for the grid cell containing the clinic.

Because the relationship between weather and disease is rarely linear, the team employed distributed lag non-linear models, a statistical framework that can capture both curved exposure-response relationships and effects that unfold over time. Weekly counts of clinic visits were highly overdispersed, so negative binomial regression was used, with natural cubic splines of time flexibly adjusting for long-term trends and seasonality. The models allowed rainfall effects to emerge across a zero-to-three-week lag window, chosen to encompass the incubation periods of the major pathogens involved as well as the time needed for environmental exposure, pathogen replication and the decision to seek care.

The headline finding is a threshold effect. For diarrheal disease, the cumulative risk of a clinic visit rose steadily as weekly rainfall increased, peaking somewhere between 35 and 40 millimetres of rain per week, after which the risk plateaued and drifted back toward null. A week with 20 millimetres of rainfall, roughly the 75th percentile of the full series, was associated with a 20 percent increase in diarrheal visits compared with dry weeks, after adjusting for temperature. Without that temperature adjustment, the apparent risk was 41 percent higher, a difference that proved to be one of the study’s most methodologically important observations.

Skin infections told a similar but not identical story. Risk climbed with rainfall up to a threshold of about 30 millimetres per week, then declined at heavier totals. Twenty millimetres of weekly rainfall was associated with a 39 percent increase in skin infection visits once temperature was accounted for, and the effect persisted across lags of one, two and three weeks, longer than the one-to-two-week window over which diarrheal risks appeared. The researchers suggest this may reflect different underlying mechanisms: diarrheal pathogens are typically ingested after relatively rapid contamination of water sources, while skin infections may follow slower routes of environmental exposure, crowding during wet weather and changes in hygiene practices when water becomes scarce or contaminated.

Stratifying the data by pathogen category revealed a striking asymmetry. Bacterial diarrheal visits carried the strongest rainfall association, with a 66 percent increase in risk at 20 millimetres of weekly rainfall after temperature adjustment, whereas viral diarrheal visits showed no clear evidence of a rainfall effect at all. A parallel pattern emerged for skin disease: bacterial skin infections were the most rainfall-sensitive category, though fungal and clinically classified local skin infections also showed elevated risks. This aligns with a growing body of evidence from other settings that rainfall and temperature shape the transmission of bacterial and viral enteric pathogens in fundamentally different ways, with wetter conditions generally favouring bacterial spread.

Age modified the risks in unexpected directions. For diarrheal disease, the rainfall association was stronger among patients aged five and over, with a 63 percent increase in risk at 20 millimetres of weekly rainfall, than among children under five, for whom no significant association was detected after temperature adjustment. The authors note that the vast majority of under-five diarrheal visits were classified as viral, which may partly explain the difference. For skin infections the pattern reversed: children under five bore the greater rainfall-associated burden, with a 77 percent increase in visits at 20 millimetres of rain, consistent with the idea that young children crawling and playing in contaminated standing water face heightened exposure. Sex-stratified analyses suggested slightly higher risks among females for both outcomes, though the evidence for modification by sex was weaker than for age.

Perhaps the most counterintuitive result concerns heavy rainfall events, defined as days receiving more than 21.05 millimetres of rain, the 95th percentile of rainy days between 2000 and 2022. In unadjusted models, weeks containing at least one such event were associated with substantially increased risks of both diarrheal and skin infection visits. But once maximum temperature was included in the models, those associations vanished entirely. And when total weekly rainfall was additionally controlled for, a heavy rainfall event was actually associated with a modest decrease in diarrheal risk. The authors propose that competing mechanisms may be at work: heavy rain can flush and dilute pathogens in water sources, while also improving water availability for hygiene, offsetting the contamination and infrastructure damage such events can cause.

The confounding role of temperature deserves emphasis, because many prior studies of rainfall and diarrheal disease have not adjusted for it at all. In The Gambia, temperature and rainfall are strongly inversely related, with the hottest weeks falling just before the onset of the rainy season. Failing to account for this coupling can therefore inflate or distort apparent rainfall effects. The sensitivity analyses were reassuring on other fronts: results held up under alternative methods of seasonal adjustment, different spline configurations, shorter and longer lag windows, and explicit adjustment for the sharp decline in diarrheal visits after rotavirus vaccine introduction in 2014. Crucially, rainfall showed no comparable association with clinic visits for routine child health checks, toothache or hypertension, outcomes that lie outside any plausible rainfall-transmission pathway, suggesting the findings are not simply an artefact of weather-driven changes in health-seeking behaviour.

The study has limitations the authors acknowledge. Clinic visits are a proxy for disease incidence rather than a direct measure, pathogen classifications rest on clinical assessment rather than laboratory confirmation, and reanalysis weather data averaged over ten-kilometre grid cells may smooth out the local extremes of rainfall that matter most. Even so, the work offers one of the most detailed pictures to date of how rainfall shapes water-related disease in West Africa, a region where such evidence has been sparse and where climate projections point toward greater rainfall variability and more intense wet-season events. As the authors conclude, the non-linear risks they document, together with the anticipated shifts in West African rainfall, argue for strengthening the climate resilience of water, sanitation and hygiene services, and for studying rainfall and temperature jointly rather than in isolation if early-warning systems for climate-sensitive diseases are to become a reality.

Subject of Research: The association between weekly rainfall, temperature and clinic visits for diarrheal diseases and skin infections in rural Gambia

Article Title: The impact of weekly rainfall on water-related diseases in The Gambia: a time-series analysis of health facility data

Article References: Bose, I., Part, C., Moirano, G., Murray, K. A., Green, R., Cerami, C., Mistry, M. N., & Kovats, S. (2026). The impact of weekly rainfall on water-related diseases in The Gambia: a time-series analysis of health facility data. Environmental Advances, 26, Article 100757. https://doi.org/10.1016/j.envadv.2026.100757

Image Credits: AI Generated

DOI: 10.1016/j.envadv.2026.100757

Keywords: rainfall, diarrheal disease, skin infections, The Gambia, time-series analysis, climate and health, heavy rainfall events, distributed lag non-linear models, water-related diseases, WASH, temperature confounding, West Africa