You take the cash meant for beans and you buy water”: The Multi‐Faceted Consequences of Water Insecurity for Pregnant and Postpartum Kenyan Women of Mixed HIV Status
Authors: Collins Shalean M , Miller Joshua D , Mbullo Patrick , Boateng Godfred O , Wekesa Pauline , Onono Maricianah , Young Sera L 
Published: November 2023

Water insecurity (WI), or the lack of safe and sufficient water for a healthy and productive life, likely has consequences that span many domains, from nutrition to economic productivity. However, consequences of WI beyond impacts on sanitation and hygiene have only recently begun to be explored, and to our knowledge, never in the context of HIV or among pregnant and postpartum women.Therefore, we explored the lived experiences of WI in a cohort of Kenyan women of mixed HIV status. We used mixed methods, including Photovoice (a participatory photo elicitation method; n=20), Go‐Along interviews (accompanied in‐depth interviews; n=20), pile sorts (organizing illustrated cards around central themes; n=20) and surveys at 8 months gestation (8m) and 3 months postpartum (3pp) with women enrolled in our longitudinal pregnancy cohort (n=371). Qualitative data were coded and analyzed in Dedoose using Grounded Theory, and quantitative data were analyzed using Stata.Our findings suggest that WI is harmful to women and their families in 5 domains: nutrition, childcare, economic productivity, and mental and physical health. Fetching water, which is calorically very costly, was the responsibility of the majority (78%) of women in our study, even in late pregnancy. They spent [mean (SD)] 4.5(6.7) hours per week traveling to, queuing, and drawing water.Impacts of WI on nutrition included changing foods being cooked [reported by 46.4% of women at 8m and 37.8% at 3pp)] and having inadequate time to prepare foods due to fetching water (reported by 22.4%). Women also discussed diverting money meant for food to purchase water and reducing the frequency and diversity of foods for adults and young children when water was limited.Fetching water prevented one quarter (23.7%) of women from caring for their children. In interviews, women reported leaving young children alone at home while fetching water. WI also impacted half of our cohort's ability to wash their children's hands and faces [51.4% (8m); 57.3% (3pp)].Economic productivity was impacted when there was insufficient water for crops or livestock [40.6% (8m); 43.3% (3pp)] and [39.9% (8m); 42.3% (3pp)], respectively. Time spent fetching water prevented 23.3% of women from engaging in income‐generating activities, and water shortages prevented a range of small business activities (e.g. hair salons, washing and selling kale).WI was a source of anxiety, with 65.5% (8m) and 69.7% (3pp) worried they would not have enough safe water to drink, and the majority (77.2%) feeling concerned for their personal safety while fetching water. During pregnancy, women mentioned fear of early labor and miscarriage from carrying water. Women experienced shame and stigma as a result of inadequate water for drinking, preparing foods, and bathing themselves and their children. WI also led to arguments [40.3% (8m); 34.3% (3pp)] and in some cases, domestic violence.Physical health consequences of WI included women [64.1% (8m); 55.4% (3pp)] drinking water they thought to be unsafe and 55.7% (8m) and 59.6% (3pp) not being able to wash hands after defecating, changing diapers, or performing other “dirty” activities. Interestingly, the frequency and severity of water insecurity did not differ by HIV status.In sum, these findings suggest multi‐faceted consequences of water insecurity that go beyond conventional associations of unsafe drinking water and poor sanitation and hygiene. We encourage further inquiry into the manifestations of WI globally.Support or Funding InformationNIH‐NIMH K01 MH098902; NIH‐NIMH R21 MHI108444