Access to safe drinking water is a fundamental human right; however, the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) report that more than 785 million people do not have access to safe drinking water (United Nations Children's Fund and World Health Organization, 2019). Globally, 29% of the population does not have access to a safely managed water source (United Nations Children's Fund and World Health Organization, 2019). Inadequate access to WaSH services is responsible for 9.1% of the global disease burden and 6.3% of all deaths worldwide (Prüss-Üstün et al., 2008). Additionally, barriers to safe drinking water often lead to various negative health outcomes such as diarrhea, cholera, trachoma, typhoid, shigellosis, and malaria (Beer et al., 2015; Bisung and Elliott, 2017; Hunter et al., 2010; Moura et al., 2019; Mourad et al., 2019; Sengupta, 2013; Tomberge et al., 2021). A global study in 2014 of 145 countries concluded that WaSH-related diarrheal deaths accounted for 1.5% of the total disease burden, 58% of all diarrheal diseases, and 9% of all deaths for children younger than 5 years old (Liu et al., 2012; Prüss-Ustün et al., 2014).

Women and girls are disproportionately affected by inadequate water access because they are largely responsible for household water management (Graham et al., 2016; Kayser et al., 2019; Pouramin et al., 2020; Tomberge et al., 2021) When water sources are not readily accessible at the home, women and girls are responsible for collecting water in 4 out of 5 households worldwide (United Nations Children’s FundWorld Health Organization, 2019). Compared to men, women experience many negative WaSH-related health outcomes, some of which have been disaggregated (Stevenson et al., 2012; Wutich and Ragsdale, 2008).Women and girls account for a higher number of deaths due to diarrheal diseases and higher disability adjusted life years (DALYs) caused by inadequate hygiene (Prüss-Ustün et al., 2019; Pal et al., 2018). Contaminated drinking water and water carriage can induce complications during pregnancy, increase perinatal health issues, negatively affect menstrual health, and increase the incidence of reproductive tract infections in women (Ademas et al., 2020; Gall et al., 2015; Geere et al., 2018a; Kayser et al., 2019).

While WaSH-related health inequities have been widely studied, relatively few studies have evaluated how drinking water impacts gender inequities (Kayser et al., 2019). Among studies that have explored the impact of drinking water on gender, the focus has been on water fetching, sanitation, and sexual violence. Women must travel long distances to retrieve drinking water and find a private place to openly defecate due to a lack of proper sanitation facilities (Sommer et al., 2015; Kayser et al., 2021). This puts them at a much higher risk of being physically assaulted, abused, or harassed (Sommer et al., 2015; Kayser et al., 2021). Among the one in three women that suffer from gender-based violence (World Health Organization, 2021), many attribute their struggle to access adequate WaSH services as a contributing factor (Sommer et al., 2015).

Women often suffer the social-educational and economic ramifications associated with finding and accessing safe drinking water (Stevenson et al., 2012, United Nations Children’s Fund, 2016). According to UNICEF, one in five girls of primary-school age are not in school, compared to one in six boys (United Nations, 2007). Young girls are often taken out of school to help manage the household while young boys are allowed to continue their education (House et al., 2012; UNICEF and WHO, 2019). Additionally, reported school absences increase when girls are menstruating due to ’inadequate WaSH facilities at school (House et al., 2012; Goodman and Norden, 2005). The lack of education regarding proper menstrual hygiene and the presence of cultural stigma causes girls to miss up to one week of school per month (House et al., 2012, Goodman and Norden, 2005). Studies suggest that such school absences contribute to high drop-out rates for girls (Vanneste et al., 2016).

This systematic review evaluates the current state of the literature regarding drinking water management and exposures and gender equity and empowerment outcomes (GEE). Drinking water management and exposures include elements of accessibility, quality, quantity, reliability, continuity (Kayser et al., 2013). GEE is defined as the association between gender and self-determination (United Nations Development Programme, 2005). Specific GEE outcomes included: psychosocial stress, political power and decision-making, health outcomes, social-educational conditions, and economic conditions. This systematic review includes both quantitative and qualitative published literature. The review assesses the relationship between drinking water and GEE outcomes and highlights areas where future research is needed. The overarching goal is to provide awareness of the connection between drinking water and GEE in order to benefit the health and wellbeing of women and girls, globally.