Residents in the Eastern Region, Ghana with access to improved water sources (e.g., boreholes and covered wells) often choose to collect water from unimproved sources (e.g., rivers and uncovered wells). To assess why, we conducted two field studies to coincide with Ghana’s rainy and dry seasons. During the rainy season, we conducted semi-structured in-depth interviews among a convenience sample of 26 women in four rural communities (including one woman in the dry season). We asked each participant about their attitudes and perceptions of water sources. During the dry season, we observed four women for ≤4 days each to provide context for water collection and water source choice. We used a grounded theory approach considering the multiple household water sources and uses approach to identify three themes informing water source choice: collection of and access to water, water quality perception, and the dynamic interaction of these. Women selected water sources based on multiple factors, including season, accessibility, religious/spiritual messaging, community messaging (e.g., health risks), and ease-of-use (e.g., physical burden). Gender and power dynamics created structural barriers that affected the use of unimproved water sources. A larger role for women in water management and supply decision-making could advance population health goals.