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Diagnostic criteria for postpartum haemorrhage treatment: a cost-effectiveness study
Nick Scott1, Ioannis Gallos2, Thomas Walsh1
1Women's, Children's, and Adolescents' Health Programme, Burnet Institute, Melbourne, VC, Australia; School of Public Health and Preventative Medicine, Monash University, Melbourne, VC, Australia.
Background:
A threshold of 500 mL or more of blood loss within 24 h 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 abnormal haemodynamic marker (pulse, systolic and diastolic blood pressure, or shock index), compared with the conventional 500 mL or more threshold.
Methods:
We developed a decision-tree model to assess the cost per disability-adjusted life-year (DALY) averted from a health-care provider perspective when the WHO PPH first-response treatment bundle was initiated using alternative criteria. Prognostic sensitivity and specificity of scenarios for identifying women at high risk of a composite outcome of maternal mortality or severe morbidity (blood transfusion, surgical intervention to stop bleeding, or intensive care admission) had been estimated using a WHO individual participant data meta-analysis of 12 datasets, comprising 312 151 women. Direct medical costs (2024 US$) were derived from a health economic study embedded within a randomised trial 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 abnormal haemodynamic marker was more cost-effective than using blood loss alone. Combining blood loss thresholds (stepwise from ≥450 mL to ≥300 mL) with any abnormal haemodynamic marker could avert 15-27% of composite outcomes, increase costs by 9-29% per woman, and have a cost of US$271-504 per DALY averted, compared with using 500 mL blood loss threshold alone. Scenarios were particularly 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 abnormal haemodynamic marker is cost-effective in improving maternal health outcomes, and cost-saving for obstetric populations with high incidence of PPH mortality and severe morbidity. Further research is needed in women undergoing caesarean birth.
Funding:
The Gates Foundation and the UNDP, UNFPA, UNICEF, WHO, and World Bank Special Programme of Research, Development, and Research Training in Human Reproduction, a cosponsored programme executed by WHO.
