Heat-stable carbetocin vs. oxytocin for the prevention of postpartum hemorrhage: a cost-effectiveness analysis based on real-world data from a pilot implementation in India

Background Postpartum hemorrhage (PPH) remains the leading direct cause of maternal mortality in India. The World Health Organization (WHO) recommends heat-stable carbetocin (HSC) as a uterotonic option for PPH prevention after all births, conditional on cost-effectiveness. This study evaluated the cost-effectiveness of introducing HSC as an alternative to oxytocin for PPH prevention within India’s public health system. Methods A decision tree–based cost-effectiveness analysis was undertaken for a hypothetical cohort of 100,000 births, comparing HSC with oxytocin for PPH prevention. Model inputs were informed by real-world data from 15 public health facilities in Dewas, Madhya Pradesh, collected during a large-scale implementation study. Costs included uterotonics, personnel, hospitalization, and referrals; health outcomes were measured in disability-adjusted life years (DALYs). Incremental cost-effectiveness ratios (ICERs) were estimated, and one-way and probabilistic sensitivity analyses were performed. Findings were extrapolated to the national and subnational (Madhya Pradesh) birth cohorts to estimate potential health and economic impacts under a universal adoption scenario. Results HSC was less costly and more effective than oxytocin, saving approximately US$473 per DALY averted. Total costs were lower for HSC (US$3.54 million) compared with oxytocin (US$3.62 million) per 100,000 births, with an 11% reduction in DALYs. One-way sensitivity analysis identified HSC’s unit cost as the most influential parameter, while probabilistic sensitivity analysis (100,000 simulations) showed HSC consistently dominated oxytocin. At the national level, universal adoption across India’s approximately 25 million annual facility-based births could avert an estimated 41,500 DALYs per year, yielding economic benefits of around US$102 million (valued at GDP per capita). In Madhya Pradesh, statewide implementation across 1.4 million births could avert about 2,300 DALYs annually, equivalent to US$5.7 million in economic gains. Conclusions In real-world conditions, HSC was a dominant and cost-effective intervention for PPH prevention in India, providing greater health benefits at lower cost compared with oxytocin. Its consistent potency in hot and humid environments and reduced need for retreatment likely contributed to this dominance. Universal adoption of HSC within India’s public health system could meaningfully reduce PPH-related morbidity and mortality, generate substantial economic savings, and support progress toward Sustainable Development Goal 3.1 and Universal Health Coverage.