Provider and facility characteristics.

Maternal mortality rates in Kenya have remained high, with the country reporting 342 deaths per 100,000 live births. A major contributor to this is postpartum hemorrhage (PPH), responsible for 40% of maternal deaths in Kenya and the leading cause globally, particularly in low- and middle-income countries. Timely and effective PPH care is crucial; however, challenges arise when referrals between facilities become necessary. Although Primary health care facilities (PHCs) in Kenya oversee many births and are crucial in PPH risk detection and management, they often fall short due to ill-equipped facilities and inefficient referral systems. This study traced PPH patients from tertiary institutions to their initial PHCs. Through qualitative interviews with healthcare providers, we aimed to examine the primary challenges in PPH management and referral decision-making. We found that, in addition to structural gaps, challenges in collaboration and communication between providers from different health facilities, which may also stem from inadequate training, greatly influenced referral efficacy. Our findings are pivotal for maternal health discourse and policy. Importantly, while many solutions focus on structural inputs, our study underscores the importance of communication between facilities in ensuring timely care. Our findings suggest a need for bolstered emergency preparedness, informed clinical decision-making, and strategic interventions where they are most impactful.