In northern Ghana’s Upper East Region, women in labour are crossing swollen rivers by canoe, walking for hours along flooded clay paths doubled over with contractions, or clinging to the back of a bicycle because no motorbike can get through the mud. Some never reach the clinic at all.
Dorcas Azongo, 29, gave birth to her twins in the yard of Bongo Hospital after crossing two rivers at night while in labour, riding part of the way on her husband’s motorcycle. “When we reached the river, it was difficult to cross because during the rainy season it is always full… I was in too much pain to speak,” she says. By the time she arrived, exhausted and in agony, it was too late to get her inside. The midwives delivered her on the ground and then cleaned her and the babies.
It was not her first dangerous delivery. Her first child was also born in the hospital yard after her husband failed to find transport. For her second, relatives balanced her on a bicycle and pushed her for nearly an hour to another clinic. “I feel bad and a bit down sometimes when I sit and think back on how difficult my deliveries were. Sometimes I feel like giving up and tell myself I never want to give birth again because of all that pain,” Dorcas says.
The journey is shaped by water. In the dry season, streams disappear and boreholes fail. When the rains come, rivers swell and cut entire communities off from hospitals and maternity wards. In villages like Beo Tankoo and Atampiisi, close to the border with Burkina Faso, pregnant women are left stranded on riverbanks in the middle of labour, waiting for canoe operators to return in the dark. “If they delay and reach the riverside and cannot cross, we sometimes have to deliver them there,” says Rejina Abane, a midwife working across remote communities in Bongo district. “Delivering on the ground is not good. There is risk of infection, and the place is not prepared. Cutting the cord and other procedures are not safe there, especially when it has rained and the ground is muddy.”
In neighbouring Atampiisi, Sophia Atule, 31, is eight months pregnant with her fifth child. She wakes before dawn to sweep, cook and queue for water at the community borehole, often spending close to two hours waiting. She knows the local clinic has no midwife and no water, and she knows the rivers well enough to have already planned the long route around to Bongo Hospital for when labour begins. “If you are in labour as a pregnant woman, the rivers are too dangerous to cross during the rainy season. When it’s rainy season and you have to go the long way, some of the women might end up delivering on their way to the facility,” she says.
Inside the clinic: no water, no toilets, no safety
The conditions inside the health centres are scarcely safer than the riverbanks. Women arrive carrying their own water from home because clinics have none. Midwives fetch buckets from distant boreholes before they can begin work. Patients needing urine tests squat behind buildings because there are no toilets. Both health centres in Beo Tankoo and Atampiisi have no running water and no borehole. Drilling attempts failed because fluoride levels in the groundwater were too high. Pregnant women are told to bring water from home for antenatal appointments, while health staff queue at a community borehole 200 to 300 metres away.
For Rejina Abane, this means starting work 90 minutes to two hours late. “That I use to fetch water I could use it to attend to three or four people, but the women are also delayed because they have to stand and wait for me,” she says. When there is no water at all, she uses hand sanitiser between palpations, knowing it is not the right protocol. “If I don’t wash my hands and continue examining women one after another, I risk spreading infections. In the end, the women may go home, develop infections and then have to go to the hospital.”
New research by development economist Guy Hutton for WaterAid puts Ghana’s annual maternal sepsis burden at 101,645 cases and 149 deaths. Improved water, sanitation and hygiene – WASH – in healthcare facilities could cut both figures roughly in half. The cost per sepsis case is estimated at $154 (£114), and across more than 100,000 cases annually that amounts to $15.7 million (£11.7m), of which $7.9 million (£5.9m) could be directly avoided with better WASH provision. Nationally, 98 per cent of health centre births in Ghana take place without basic sanitation, and a third happen without any water access at all.
WaterAid’s “Born without water” report found that in 16 Sub-Saharan African countries, 76 per cent of births occur in “unsafe” delivery rooms lacking basic WASH essentials. Globally, a woman gives birth every two seconds in a healthcare facility without access to clean water, exposing more than 16 million women each year to life-threatening infections. A mother in Sub-Saharan Africa is 144 times more likely to die from maternal sepsis than one in Western Europe or North America.
The crisis is deepening. The Upper East Region recorded 60 maternal deaths in 2025, up from 42 in the same period in 2024, according to the regional health authorities. The institutional maternal mortality ratio rose to 132 per 100,000 live births from 97 the previous year, far exceeding both the national average and Ghana’s Universal Health Coverage target of 70 deaths per 100,000 live births by 2030. Neonatal mortality increased from 5 to 6 per 1,000 live births, and the stillbirth rate remained stagnant at 9.9 per cent, missing the 2025 target of 11.5 per cent. Contributing factors include shortages of blood and oxygen, weak referral systems, poor roads, financial barriers, and high rates of anaemia in pregnancy – 17,377 cases recorded in 2025.
Aid cuts threaten fragile progress
The crisis comes as aid agencies warn that years of progress on maternal health across parts of Africa are becoming increasingly fragile as deep cuts begin to bite. In January 2025, the administration of US President Donald Trump functionally dismantled the United States Agency for International Development (USAID), with more than 80 per cent of its programmes stopped or terminated. The UK followed in February 2025 with a 40 per cent cut to its foreign aid budget, and bilateral aid to Africa is set to be slashed by 56 per cent by 2028-29, redirected to fund national defence spending. The cuts were announced by UK Foreign Secretary Yvette Cooper.
Across this period, the UN Population Fund has recorded sharp drops in procurement of essential supplies across sub-Saharan Africa. Organisations that relied on US bilateral funding to run community health programmes are operating on emergency reserves or not operating at all. Studies project that the US cuts could lead to millions of additional deaths between 2025 and 2040. WaterAid staff working in Ghana say clinics in Bongo district still lack the most basic water, sanitation and hygiene infrastructure needed for safe childbirth, and the money that was already too thin is getting thinner.
“Women are being forced to risk their lives in labour, crossing flooded rivers just to reach basic care. No woman should have to endure this to give birth safely,” says Ewurabena Yanyi-Akofur, WaterAid Ghana’s country director. “This crisis highlights how essential water, sanitation and hygiene are to maternal health and how climate change is making an already difficult situation worse. I see every day how women are disproportionately affected. It is deeply disheartening that running water in a healthcare facility is still considered a luxury when it should be the standard.”
WaterAid and local authorities are attempting to change this through a project called Good Health Begins Here, which aims to install mechanised solar-powered water systems, storage tanks, toilets and incinerators at clinics including Beo Tankoo and Atampiisi – infrastructure designed to handle the fluoride problem that defeated previous drilling attempts and eventually to make a permanent midwife posting viable. The sanitation work has started but the water is not yet in. Fatima Mumuni, an engineering technician with the Bongo district assembly, says the ambition goes beyond a new borehole: “In these communities, people usually get water from boreholes within the community and bring it to the health centres. If somebody is about to give birth, they have to carry their water from their house.” She hopes the new infrastructure will change that.
In September 2025, the Bongo District Assembly, in partnership with WaterAid and other stakeholders, signed a landmark WASH Compact committing to achieve universal access to safe water, sanitation and hygiene services within ten years. WaterAid’s Time to Deliver campaign is calling for urgent investment to ensure every health facility in Ghana has safe water and decent sanitation by 2026.
For now, the rivers still rise when the rains come. Women still arrive at clinics carrying jerrycans alongside their hospital bags, and midwives are still spending the first hours of their working day searching for enough water to wash their hands.