Cost-effectiveness of diagnostic criteria for postpartum haemorrhage treatment

A threshold of ≥ 500 ml blood loss within 24 hours of childbirth has conventionally been used to initiate postpartum haemorrhage (PPH) treatment. We assessed the cost-effectiveness of initiating PPH treatment at lower blood loss thresholds, alone and in combination with any other abnormal haemodynamic marker (pulse, systolic and diastolic blood pressure, shock index), compared with the conventional ≥ 500 ml threshold.

A decision tree model was developed to assess the cost per disability-adjusted life years (DALYs) averted from a healthcare provider perspective when the World Health Organization (WHO) first-response treatment bundle was initiated using alternative criteria. Sensitivity and specificity of scenarios for identifying women at high risk of a composite outcome of maternal mortality or severe morbidity was estimated using a WHO individual participant data meta-analysis. Direct medical costs (2022 US$) were derived from randomised trial data in Kenya, Nigeria, South Africa, and Tanzania. Findings Treatment initiation based on lower blood loss thresholds could avert additional composite outcomes. Use of lower blood loss thresholds in combination with any other abnormal haemodynamic marker was more cost-effective than blood loss alone. Combining blood loss thresholds (stepwise from 450 to 300 ml) with any other abnormal haemodynamic marker could avert 15–27% of composite outcomes, increase costs by 9–30% per woman, and have a cost of US$260–479 per DALY averted, compared to using 500 ml blood loss alone. Scenarios were more cost-effective for vaginal births, and cost-saving for populations with a composite outcome incidence ≥ 9%. Interpretation Expanding the conventional criteria for initiating PPH treatment to include lower blood loss thresholds in combination with any other abnormal haemodynamic marker is cost-effective in improving maternal health outcomes, particularly for obstetric populations with high incidence of PPH mortality and severe morbidity. Further research is warranted in women undergoing caesarean birth. Funding This study was funded by The Gates Foundation (INV-063940) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization. Evidence before this study A threshold of 500 ml or more blood loss after childbirth has conventionally been used to initiate treatment for postpartum haemorrhage (PPH). Lower blood loss thresholds in combination with any other abnormal haemodynamic marker have been proposed as newer alternative diagnostic criteria to prompt earlier treatment and potentially improve maternal outcomes. However, such approaches risk overtreatment and higher costs which are critical considerations in low-resource settings where the burden of PPH morbidity and mortality is greatest. Until recently, limited evidence on the prognostic accuracy of clinical markers of postpartum bleeding in predicting maternal mortality and morbidity prevented robust cost-effectiveness analyses of diagnostic criteria for PPH treatment initiation. In 2025, the World Health Organization (WHO) concluded a prognostic accuracy study based on individual participant data (IPD) meta-analysis including 312 151 women from 12 datasets. The prognostic accuracy study estimated the sensitivity and specificity of clinical markers of postpartum bleeding (blood loss, pulse, systolic and diastolic blood pressure, and shock index) in predicting a composite outcome of maternal mortality or severe morbidity (blood transfusion, surgical intervention to stop bleeding, or intensive care admission), providing the first opportunity to evaluate the economic implications of alternative criteria for initiating PPH treatment compared to the conventional 500 ml or more blood loss threshold. Added value of this study Building on the WHO IPD meta-analysis, we assessed the cost-effectiveness of initiating PPH treatment at lower blood loss thresholds (stepwise from 450 ml, 400 ml, 350 ml, 300 ml), alone and in combination with any other abnormal haemodynamic marker (defined as abnormal pulse rate, systolic or diastolic blood pressure, or shock index), compared with the conventional ≥ 500 ml blood loss threshold. Where treatment initiation was based on lower blood loss thresholds and any abnormal haemodynamic marker, the 500 ml blood loss threshold was retained as an additional criterion, to ensure that women who continue to bleed in the absence of any other abnormal haemodynamic marker still receive treatment as per current convention. We found that lower blood loss thresholds could avert additional composite outcomes, but diagnostic criteria combining lower blood loss thresholds with any other abnormal haemodynamic marker were more cost-effective than those based on blood loss alone, owing to higher specificity and reduced overtreatment. Compared with 500 ml blood loss alone, the cost per disability-adjusted life year (DALY) averted for treatment initiation at 300 ml plus any other abnormal haemodynamic marker (US$479) represents less than 100%, 50%, and 25% of gross domestic product (GDP) per capita for 97%, 85%, and 70% of low- and middle-income countries. For vaginal births, the cost per DALY averted (US$77) was less than 25% of GDP per capita for 99% of low- and middle-income countries. In high-risk obstetric populations with ≥ 9% incidence of the composite outcome, all scenarios combining blood loss with any other abnormal haemodynamic marker were cost-saving (compared to 2.5% incidence in the IPD meta-analysis). Implications of all the available evidence From a health economics perspective, our findings support expanding diagnostic criteria for initiating PPH treatment to include blood loss thresholds lower than 500 ml in combination with any other abnormal haemodynamic marker. This strategy improves maternal outcomes at acceptable or favourable cost-effectiveness ratios, particularly in low-resource settings with high burden of life-threatening PPH complications. As most women in the WHO IPD meta-analysis had vaginal births, further research is warranted to evaluate the cost-effectiveness of expanded treatment initiation criteria for caesarean births. Competing Interest Statement IG, IY, GJH, AD, ZPQ, AC, and OTO were co-authors for E-MOTIVE trial, the largest included trial in the WHO individual participant data that underpinned this cost-effectiveness analysis. GJH previously received consultancy payments as inventor of the MaternaWell Tray for blood loss monitoring after birth, but has no current or future financial interest. LS has received consulting fees and payment/honoraria from Ferring Pharmaceuticals, Bayer, GlaxoSmithKline, Pfizer, Organon and Norgine. All other authors declare no competing interests. Funding Statement This study was funded by The Gates Foundation (INV-063940) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Eligible studies for the WHO individual participant data meta-analysis must have had prior ethics committee approval and the data holder had to be able to enter into a legal data sharing agreement with WHO. Institutional review board approval was not required for this study because only previously collected, de-identified data were used. All contributing studies had received appropriate ethical approvals, and no new participant recruitment or data collection was undertaken for the current study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability All model parameters used for this study are available in the manuscript and supplementary material, extracted from the sources as cited. The individual participant data (IPD) that served as the basis for this article were shared with the WHO exclusively for the purpose of conducting this IPD meta-analysis to reappraise the definition of PPH. Researchers interested in accessing data from the original studies should contact the corresponding authors of those studies directly. Access will be subject to the approval of data owners and applicable data sharing agreements.