RT Journal Article SR Electronic T1 Community-level impacts of sanitation coverage on maternal and neonatal health: a retrospective cohort of survey data JF BMJ Global Health JO BMJ Global Health FD BMJ Publishing Group Ltd SP e005674 DO 10.1136/bmjgh-2021-005674 VO 6 IS 10 A1 Brittany L Kmush A1 Bhavneet Walia A1 Anushruta Neupane A1 Carolina Frances A1 Idris Ahmed Mohamed A1 Mahwish Iqbal A1 David A Larsen YR 2021 UL http://gh.bmj.com/content/6/10/e005674.abstract AB Introduction Access to sanitation facilities (toilets or latrines) greatly improves human health. Low community sanitation coverage may lead to increased exposure to pathogens for households both with and without a sanitation facility.Methods We created a retrospective cohort using Demographic and Health Surveys from 1990 through 2018. Using regression with matched women as a random intercept, we assessed the association between community-level sanitation coverage and neonatal mortality (Poisson model, n=1 254 862 live births, 187 datasets), small birth size (logit model, n=1 058 843 live births, 187 datasets) and anaemia (logit model, n=1 304 626 women, 75 datasets).Results Among women with household sanitation, the incidence of neonatal death (incidence rate ratio: 0.85, 95% CI 0.77 to 0.93), the odds of small birth size (OR: 0.81, 95% CI 0.76 to 0.87) and anaemia (OR: 0.82, 95% CI 0.79 to 0.85) were lower for women in communities with 100% sanitation coverage compared with 1%–30% (p≤0.001 for all). There was no difference in neonatal deaths between women in communities with 31%–99% sanitation coverage compared with 1%–30% (p≥0.05). Among women without household sanitation, there were no differences in neonatal mortality by community sanitation (p≥0.05). The odds of small birth size were decreased (OR: 0.91, 95% CI 0.87 to 0.97, p=0.003) for women in communities with 61%–99% sanitation coverage compared with 1%–30%; there was no association with the other community sanitation categories (p≥0.05). The odds of anaemia were increased (OR: 1.08, 95% CI 1.06 to 1.11, p<0.001) for women living in communities with 0% sanitation coverage compared with 1%–30%, but no association with the other community sanitation categories (p≥0.05).Conclusion Community sanitation coverage is associated with improved maternal and neonatal outcomes, particularly among women with household sanitation. This suggests that the impact of sanitation coverage on maternal and neonatal health is underestimated unless the community-level effects are considered.Data are available in a public, open access repository. All data is available to the public from the Demographic Health Surveys (DHS) established by United Stated States Agency for International Development (USAID) available at https://dhsprogram.com.