By PPH Foundation

When postpartum haemorrhage, PPH, occurs outside a health facility, the emergency may become invisible long before it becomes a statistic. A woman may give birth at home, begin bleeding heavily and face delays in recognising the danger, finding transport or reaching appropriate care. If she dies before reaching a facility, or survives without seeking formal care, the episode may never appear in routine clinical records.

Kenya's 2022 Demographic and Health Survey found that 88 per cent of live births occurred in health facilities, leaving about 11 per cent taking place at home. However, the national figure masks significant county-level differences. Home births accounted for 50 per cent of births in Mandera, 48 per cent in Tana River, 47 per cent in Turkana, 46 per cent in Wajir and 45 per cent in Samburu. In these settings, maternal emergencies occurring outside facilities may represent a more significant part of the country's PPH burden than national averages suggest.

The challenge is that facility-based data naturally capture women who reach hospitals and health centres. They can document blood loss, treatment, referrals and outcomes. Outside the health system, however, information can be lost at every stage. A family may not recognise severe bleeding as an emergency, struggle to find transport or face long distances to care. A woman may also survive a severe haemorrhage at home without the episode ever being formally recorded.

This matters because PPH can progress rapidly and requires timely recognition and treatment. The World Health Organization emphasises that severe bleeding after childbirth can become fatal within hours without appropriate care.

Prof Anne-Beatrice Kihara, Co-Lead of the End PPH Initiative, and colleagues, in their 2025 paper on gender inequity and PPH, highlight how access to care, socioeconomic circumstances, decision-making autonomy and sociocultural factors can influence maternal outcomes. Their work reinforces the importance of looking beyond what happens inside the health facility to understand the barriers women face before they receive care.

Making these cases visible requires stronger links between communities and formal health information systems. Community health workers, referral networks, maternal death surveillance, civil registration and facility records can collectively help identify emergencies that would otherwise remain undocumented.

Technology can strengthen these connections, but better data must be linked to action. Knowing that a woman is experiencing a maternal emergency is meaningful only if the system can respond with transport, skilled care, medicines and blood.

The invisible haemorrhage burden is therefore more than a data gap. It is an equity issue. If Kenya is to reduce preventable deaths from PPH, maternal health systems must understand not only what happens inside maternity wards, but also what happens before a woman reaches them.

References

1. Kenya National Bureau of Statistics, KNBS. 2023. Kenya Demographic and Health Survey 2022. Nairobi, Kenya.
2. Kihara, A.-B., Oguttu, M., Gülmezoglu, A. M., et al. 2025. Gender inequity in postpartum hemorrhage: A public health issue. International Journal of Gynecology & Obstetrics, 171, 965–969.
3. World Health Organization. 2025. Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage. Geneva: WHO.
4. Coomarasamy, A., Devall, A. J., Bell, S., et al. 2026. Diagnosis and treatment of postpartum haemorrhage: a race against time. The Lancet, 408, 83–92.
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