Pregnant women and babies are in danger when hospitals have no essential services. Wards and equipment can’t be cleaned. Midwives and doctors can’t wash their hands during care or safely dispose of medical waste.
16.6 million women will give birth in 2023 at health centres without adequate water, sanitation and hygiene. That’s one woman every two seconds.
From dangerous walks for water to unsafe childbirth, this collection, Carrying Life, provides an intimate insight into the physical and psychological burdens for women living without clean water, decent toilets and good hygiene.
Through their strength and collective struggle, we see the tender moments that keep life flowing in the most difficult circumstances.
In Ntchisi District, Malawi, most villages are situated a few miles from healthcare facilities. This means that when a woman is in labour, she will need to be transported by bicycle, oxcart, or vehicle along bumpy dirt roads – and risk giving birth on the way.
To avoid this, expectant mothers are encouraged to stay at clinic lodgings at least a month before their due date. These are known as ‘guardian shelters’.
Here, the expectant mother is usually cared for by representatives – most often her mother and her mother-in-law. These are her ‘guardians’.
Guardians typically cook, wash and care for the mothers as they wait for active labour and their trip to the wards. To pass the time, the women engage in collective prayer, singing, dancing, and the occasional game of netball.
Nearly one in four healthcare facilities in Malawi operate without clean water. As many as three in five don’t have decent toilets, and more than half have no hygiene facilities. This has a direct impact on women and guardians using the shelters.
Enala Etifala, 19, lives in the village of Thandu, near Kangolwa Health Centre. She gave birth a year ago, before the centre had a supply of clean water.
“My guardian had to get water from a stream so that I could bathe and clean myself after the birth. The water was dirty and not good. I could see things settling to the bottom of the bucket. I had to use the same water to drink from.
“We didn’t have a choice. We couldn’t bring water from home as it was too far. We had to make do with what we had at the hospital.
“I am delighted to be a mother and realise that now I will always have a friend in my baby. My baby likes to laugh a lot, which makes me laugh a lot too.”
Women like Enala shouldn't start their journey into motherhood without clean water, decent toilets and good hygiene.
Ntchisi District is in the Central Region of Malawi, about 60 miles north of the capital city of Lilongwe. Many local communities still have no basic services because the district is far from main roads and hard to reach.
Building clean water points and toilets in Ntchisi’s healthcare centres is a first step in making these basic human rights part of daily life for thousands of residents.
WaterAid Malawi have been working with healthcare facilities across the country since 2014. With funding from the Wimbledon Foundation, and support from local partners, they have recently installed new facilities in Ntchisi District Hospital, and Kangolwa, Nkhuzi and Khuwi Health Centres.
Together, these four clinics will provide clean water, decent toilets and good hygiene to around 317,000 patients. WaterAid Malawi has also provided clean water at a further six healthcare centres across Ntchisi district.
Lustiya Samalani, 34, pictured below is a mother to four children, all of whom were delivered at Nkhuzi Health Centre before it had clean water and decent toilets.
Her time at the health centre was very challenging.
“There was no water and no proper toilet. The patients and their guardians didn’t have a choice but to go in the nearby fields to relieve ourselves whenever we needed the toilet.
"Guardians at the facility would have to trek down to the local borehole, and the water would then be used for both cleaning and bathing.
“The situation has really improved at the health centre now. There are now proper sanitation facilities and we are able to wash our hands properly.”
Eliza Tobias, 20, and Alefa Banda, 22, are sisters-in-law. Eliza, pictured below, gave birth at Ntchisi District Hospital when it still had no clean water or decent toilets.
“I only stayed at the guardian shelter for four days, but it was the longest four days! The toilets were too full. I couldn’t even use them. Can you imagine using a toilet that is full up?
“There was a tap there, but sometimes it was dry. There wasn’t enough water. We had to go down to a school with a borehole.
“It was so disturbing that the women didn’t have the dignity they deserved. They didn’t have a choice – they couldn’t go in the toilet and they couldn’t go anywhere else. They are heavily pregnant, what do they do?”
To avoid a similar experience, Alefa, pictured right, did not stay at the shelter and walked to the hospital when her labour began.
“When thinking about conditions at the guardian shelter, I decided it was safer to stay home and go when labour started. I started walking at 6am and I got there around 8:30am.
“At some point, I had to stop and lie down on the road to rest because I was in so much pain. I was so scared I would give birth on the road. There are so many people passing by, it would have been undignified to give birth there.
“This time around, I would definitely go to the guardian shelter, as I know they have better facilities now.”
Eliza, left, agrees:
"I’ve seen the new toilets. They are good! I was visiting someone at the guardian shelter and I thought, ‘Wow, things have really improved here.’”
Globally, women and girls are responsible for collecting water in 8 out of 10 households where they don’t have water at home.
In the village of Chimwala, some women fetch water by night to avoid long queues at the pump during the day.
This can be frightening. Once, a group experienced what they believed was a supernatural being, or witch, standing ahead of them on the road in the darkness. They ran home, terrified.
However, with no other clean water source, the women continue to collect water at night. They fear another encounter, but it is the only way to provide for their families.
Delia Laiford, 56, is a grandmother from a village near Kangolwa Health Centre. To date, she has lived her whole life without water nearby.
To get water, she currently has two choices. She can buy it from a borehole in a neighbouring village – something she can’t afford and doesn’t like because of how she is treated. Or she can collect it from a natural spring behind her house – down a steep hill and a dangerous path.
“Water is something I wake up every day worrying about. I have so many worries, it is like I have nowhere to run to. I have lots to worry about. Things aren’t adding up.”
Delia has given birth 14 times during her life, but only six of her children survived. She has been a guardian “countless times”.
When told about the new taps and toilets at Kangolwa Health Centre, she is delighted by the changes happening.
“My previous stay there was so challenging. I would gladly go there and be a guardian now! Actually, I’m looking forward to it, because I know I won’t experience what I did before. I would go with peace of mind that everything is fine.”
WaterAid Malawi collaborated with Ntchisi District Council to provide Kangolwa Health Centre with a supply of clean water – pumping it from a community well a kilometre away.
The well originally served three villages, and thanks to a sustainable plan, it still does. Its water is drawn up and stored in a 10,000-litre tank, then distributed to three new water kiosks serving the 400 residents.
Now the well also supplies Kangolwa Health Centre, something the residents of Thandu village are very pleased about as it means they will be able to access clean water when visiting the health centre. They are also proud their water is helping others.
Fayinesi Gilbert, 54, is a farmer and mother of seven living in Thandu, a village close to the Kangolwa Health Centre. She recalls when she first gave birth there in 2004.
“There was no water at all. We had to go behind the guardian shelters to the river to get water for use at the hospital – for bathing and whatever else we needed.”
Fayinesi is delighted that Thandu now shares its water supply with the health centre. She recognises the change this essential human right brings to whole communities.
“They have started pumping water from here, all the way there. Things have improved right before my eyes and I’m proud!”
Lustiya Banda, 32, has given birth to her fourth child, and her experience is different from her previous three deliveries. This is thanks to the new taps, showers and toilets installed at Nkhuzi Health Centre.
“My labour started two days ago. Yesterday, I was in labour for the whole day and night, then I delivered this morning. I feel overjoyed now.
“I am waiting to bathe for the third time. I went in the new showers outside. I’ve had a well-cooked meal. When I need to wash my hands, there is water available.
“I hope for a bright future for my baby. I hope she will grow and blossom.”
Basic services make a crucial difference in healthcare facilities. Their impact on the physical and emotional wellbeing of women in Ntchisi is already clear.
Around the world, dirty water impacts women at every stage of their lives. By reaching everyone, everywhere with clean water, decent toilets and good hygiene, we can give every woman a chance to thrive.
Building clean water sources and toilets in communities and healthcare facilities reduces women’s contact with dirty water and unhygienic settings. This will radically improve their health in the long term and give back time for other activities.
Women have specific health needs but will never have equal health prospects without basic services. Ensuring every woman has clean water, decent toilets and good hygiene will change the future for good.
No woman should start their journey into motherhood without these vital essentials.
The Wimbledon Foundation, official charity of The All England Lawn Tennis Club and The Championships, funded new water and toilet facilities in four healthcare facilities in Ntchisi, Malawi.