By PPH Foundation

Postpartum haemorrhage is one of the leading causes of maternal death worldwide, yet clinical factors tell only part of the story. Decisions made in the home about whether, when, and how to seek care often determine whether a woman survives severe bleeding after childbirth. Across many low‑ and middle‑income countries, women’s ability to make timely decisions about maternal health is constrained by gender norms and household power structures, creating a form of gender‑related risk that directly increases the danger of PPH.

Research shows that delayed decisions to seek emergency obstetric care are common in settings where women must first obtain permission from relatives or male partners. In a study of postpartum mothers in the South Gondar zone of Ethiopia, more than one‑third of women experienced delays in deciding to seek emergency care, with unplanned pregnancy and a lack of health facilities among the key factors associated with delay. These delays contribute directly to poor outcomes, including haemorrhage, because any delay in reaching skilled care increases the opportunity for complications to escalate.

A systematic review into decision‑making autonomy in maternal health services across low‑ and middle‑income countries found that overall autonomy is limited, with only about half of women able to make independent decisions about their care. Women’s ability to decide about antenatal attendance, delivery location, and postnatal care was significantly lower among younger, uneducated, rural, and economically constrained women, the very conditions that increase risk for PPH and other maternal complications.

Gender inequities in healthcare access and decision‑making power are well‑documented in contemporary maternal health literature. A global analysis by Professor Anne‑Beatrice Kihara and colleagues emphasises that postpartum haemorrhage disproportionately affects women in low‑resource settings not only because of clinical conditions, but also due to sociocultural norms that limit women’s autonomy. In these contexts, decisions about seeking care are often made by male partners or elders who may lack maternal health knowledge or who prioritize other household needs over rapid care‑seeking. Kihara’s work highlights that gender inequity manifests as delayed care‑seeking, limited access to skilled birth attendants, and reduced emergency obstetric care, all of which exacerbate PPH risk.

Prof Anne-Beatrice Kihara, a Co-lead at the End PPH Initiative, explains that “when women lack decision‑making power within their households, they are more likely to delay seeking care for life‑threatening complications like PPH. Efforts to prevent postpartum haemorrhage must therefore address not just clinical capacity but also the social and gender structures that determine who makes the care decisions.”

Qualitative evidence from studies of care‑seeking behaviours reinforces this picture. Research across sub‑Saharan Africa shows that once symptoms of complication are recognized, care‑seeking is often delayed further as partners, traditional birth attendants, and older relatives negotiate the decision. In many instances, the woman experiencing complications has little direct agency in that choice, even when the severity of her condition is clear. Such negotiation often results in additional delays as symptoms worsen.

The implications of these findings are profound. Interventions to reduce PPH mortality cannot focus solely on improving clinical protocols; they must also empower women within households, support shared decision‑making, and engage family members as partners in maternal health. Community education campaigns that explicitly involve men and elders have been shown to improve recognition of danger signs and decrease delays in seeking care for maternal emergencies. When women have greater autonomy over reproductive and maternal health choices, they are more likely to seek timely care, increasing the chances of survival when PPH occurs.

Protecting women from preventable maternal deaths, therefore, requires a dual focus: strengthening health systems to deliver quality obstetric care and transforming social norms so that women are recognized as active decision‑makers in their own health. Only by addressing both the clinical and the social determinants of PPH can we begin to eliminate deaths that should never occur.

Sources

Anne‑Beatrice Kihara, Monica Oguttu, Ahmet Metin Gülmezoglu, et al. Gender inequity in postpartum hemorrhage: A public health issue. International Journal of Gynaecology and Obstetrics. 2025;171(3):965‑969.

Gebrehiwot Ayalew Tiruneh, Dawit Tiruneh Arega, Bekalu Getnet Kassa. Delay in making decision to seek emergency obstetric care among postpartum mothers in South Gondar zone hospitals. Heliyon. 2022.

Natnael Atnafu Gebeyehu, Kelemu Abebe Gelaw, Eyasu Alem Lake, et al. Women’s decision‑making autonomy in maternal health services in low‑ and middle‑income countries: Systematic review and meta‑analysis. Women’s Health. 2022.

Evidence on care‑seeking pathways and decision dynamics during maternal complications (multiple authors). BMC Pregnancy and Childbirth. 2025.

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