Cost-effectiveness of diagnostic criteria for postpartum haemorrhage treatment

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.