Global WASH frameworks address water access, sanitation infrastructure, and handwashing. Genital hygiene does not appear. Yet a systematic review of non-antibiotic interventions for UTI prevention in pregnancy found genital cleansing to be the most effective measure available. This page is about the gap between that evidence and the frameworks meant to act on it.
A systematic review of non-antibiotic measures for the prevention of urinary tract infections in pregnancy identified genital cleansing as the single most effective intervention — outperforming hydration, probiotics, and other behavioural hygiene practices. UTIs in pregnancy are among the most common drivers of preterm birth and low birth weight globally, and in low-resource settings they frequently go untreated.
Despite this evidence, no genital wash concept exists within established WASH frameworks. The seminal framework paper "Getting the basic rights — the role of water, sanitation and hygiene in maternal and reproductive health" maps WASH interventions across the reproductive health pathway but does not include genital hygiene as a category. The gap is structural, not incidental — and it has persisted while the evidence has continued to accumulate.
Genital cleansing was identified as the most effective non-antibiotic intervention for UTI prevention in pregnancy. It has no place in WASH programming.
Prospective studies have demonstrated a direct association between genital hygiene practices and urinary tract infection risk during pregnancy. Sexual activity and inadequate periurethral hygiene are among the strongest modifiable risk factors identified, pointing to both male and female genital hygiene as clinically relevant variables.
Impact of genital hygiene and sexual activity on urinary tract infection during pregnancy
A systematic review of non-antibiotic measures for UTI prevention in pregnancy ranked genital cleansing as the most effective intervention across all categories examined. This finding has not been translated into any WASH programme, clinical guideline, or public health campaign at scale.
A systematic review of non-antibiotic measures for the prevention of urinary tract infections in pregnancy
The most widely cited conceptual framework for WASH in maternal and reproductive health maps the role of water, sanitation, and hygiene across the birth pathway — from pre-conception through the postnatal period. Genital hygiene does not appear as a category. The framework is comprehensive in its scope; its omission of this domain reflects a field-wide blind spot.
Campbell OMR, Benova L, Gon G, Afsana K, Cumming O (London School of Hygiene & Tropical Medicine). Getting the basic rights – the role of water, sanitation and hygiene in maternal and reproductive health: a conceptual framework. Trop Med Int Health. 2015;20(3):252–267. doi:10.1111/tmi.12439
The Circunaro device — a medical-grade silicone ring designed to maintain aeration of the subpreputial space — is one concrete example of what a genital hygiene intervention could look like in practice. It is water-independent, non-antibiotic, reversible, and manufacturable at low cost. It was previously CE-marked as a Class I medical device and has a six-year commercial safety record.
But the broader point is not about this device. It is about the absence of a category. Without genital hygiene as a recognized domain within WASH, no such intervention — however evidence-grounded — can be systematically evaluated, funded, or scaled. The Circunaro device is an example of an unexploited opportunity that exists precisely because the conceptual framework does not.
We have contacted investigators who have established a consortium for EDCTP3 and shared a proposal to implement this new framework in a field setting. The ADJUNCT-SYPH study represents the first concrete application of a male genital hygiene intervention designed within a genital-WASH-informed research framework — evaluating a reversible silicone ring worn by male partners to optimise the durability of benzathine penicillin G treatment in women with syphilis.
The Ugandan investigators we are engaging to take this work into the field include Godfrey Kigozi, Ronald Moses Galiwango, Gertrude Nakigozi, Fred Nalugoda and Stephen Mugamba — researchers with the Rakai Health Sciences Program (RHSP) and the Africa Medical and Behavioural Sciences Organization (AMBSO), Uganda.
In parallel, we want to take the concept back to its source. The conceptual framework above was developed by researchers at the London School of Hygiene & Tropical Medicine (LSHTM) — Campbell, Cumming and colleagues. We are seeking to engage that group, and the wider WASH research community, to formally extend the framework so that genital hygiene is recognised as a distinct WASH dimension within maternal and reproductive health — the missing category that would allow interventions like the one tested in ADJUNCT-SYPH to be evaluated, funded and scaled.
We are seeking researchers, public health practitioners, and WASH programme designers willing to explore what a genital hygiene component within WASH frameworks could look like. Addressing this conceptual gap is, we believe, essential for improving maternal and reproductive health outcomes globally. If your work touches these areas, we want to hear from you.
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