The Cost-Effectiveness of Preventing, Diagnosing, and Treating Postpartum Haemorrhage: A Systematic Review of Economic Evaluations

Joshua F. Ginnane, Samia Aziz, Saima Sultana, Connor Luke Allen, Annie McDougall, Katherine E. Eddy, Nick Scott, Joshua P. Vogel

Abstract

Postpartum haemorrhage (PPH) is an obstetric emergency. While PPH-related deaths are relatively rare in high-resource settings, PPH continues to be the leading cause of maternal mortality in limited-resource settings. We undertook a systematic review to identify, assess, and synthesise cost-effectiveness evidence on postpartum interventions to prevent, diagnose, or treat PPH.

Introduction

Postpartum haemorrhage (PPH) is a time-critical obstetric emergency, defined by the World Health Organization (WHO) as postpartum blood loss of more than 500 ml, regardless of mode of birth [1]. PPH affects approximately 6% of women giving birth and is the most common direct cause of maternal mortality, responsible for an estimated 19.7% of maternal deaths [2,3]. The incidence and resulting maternal mortality caused by PPH are disproportionately concentrated in low- and middle-income countries (LMICs) [4]. In addition to the health considerations, PPH also burdens health systems financially. Births complicated by PPH incur costs 21% to 309% higher than births without complications in LMICs [5].

Methods

For this review, we followed guidelines from the Expert Review of Pharmacoeconomics and Outcomes Research [14] and reported findings in line with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) 2020 statement (Table A in S1 Appendix) [15]. We prospectively registered the review protocol on PROSPERO (CRD42023438424). All included articles have been previously published, and ethics approval was not required.

Results

Searches identified 3,993 citations, of which, 56 were eligible for inclusion (Fig 1; see Table A in S5 Appendix for excluded studies). Two additional citations were identified after reference review. Of the 58 total eligible citations, 2 (2/58) were found to be additional publications from the same studies meaning only 56 unique studies were identified. Of the included studies, 33 (33/56) assessed PPH prevention interventions, 1 (1/56) assessed prevention versus treatment, 1 (1/56) assessed a diagnostic method alone, 17 (17/56) assessed PPH treatments, and 4 (4/56) assessed combinations (bundles) of prevention and treatment, or diagnosis and treatment (Fig 2). Studies were published between 2006 and 2024 and were conducted in low-income (3/56), lower-middle income (14/56), upper-middle income (8/56), and high-income (24/56) countries. Seven (7/56) studies were completed across multiple income level settings.

Discussion

This is, to our knowledge, the first systematic review examining the cost-effectiveness of interventions for PPH across the continuum of prevention, diagnosis, treatment, or combinations of these. We identified 56 studies—approximately half (24 studies) were conducted in high-income settings. Despite this considerable body of economic evidence for PPH-related care, the interventions, evaluation methodologies, time horizons, and perspectives varied considerably between studies. Acknowledging this heterogeneity, some patterns emerged. Currently, no injectable uterotonic agent or combination is universally dominant from a cost-effectiveness perspective.

Conclusion

This review has collected, summarised, and highlighted important health economic findings from 56 studies across 16 interventions for the prevention, diagnosis, and treatment of PPH. We identified consistent evidence that adding tranexamic acid to PPH treatment regimens is a dominant strategy and that combining PPH interventions into bundles can deliver improved health outcomes for modest cost. We also identified significant gaps in the cost-effectiveness evidence for PPH interventions. Of the 29 WHO recommendations, 16 do not have any cost-effectiveness evidence, and further assessments of widely used interventions for PPH treatment such as additional uterotonics, non-pneumatic anti-shock garment, or uterine balloon tamponade are urgently needed.

Citation: Ginnane JF, Aziz S, Sultana S, Allen CL, McDougall A, Eddy KE, et al. (2024) The cost-effectiveness of preventing, diagnosing, and treating postpartum haemorrhage: A systematic review of economic evaluations. PLoS Med 21(9): e1004461. https://doi.org/10.1371/journal.pmed.1004461

Editor: Andrew Shennan, King’s College, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND

Received: April 23, 2024; Accepted: August 14, 2024; Published: September 13, 2024

Copyright: © 2024 Ginnane et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting information files.

Funding: J.F.G. received a Shark Tank Grant from the Burnet Institute, Melbourne (no grant number available) for this review. J.P.V. is supported by an Australian National Health and Medical Research Council Emerging Leadership Investigator Grant (GNT1194248). Funders played no role in the study design, data collection, analysis, narrative synthesis or writing of this review.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: CCEMG, Campbell and Cochrane Economics Methods Group; DALY, disability-adjusted life year; GDP, gross domestic product; LMIC, low- and middle-income country; MMR, maternal mortality ratio; NASG, non-pneumatic anti-shock garment; PCVT, point-of-care viscoelastic testing; PPH, postpartum haemorrhage; PPP, purchasing power parity; PSA, probabilistic sensitivity analysis; TBA, traditional birth attendant; UBT, uterine balloon tamponade; VHW, village health worker; WHO, World Health Organization

 

 

 

Source: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004461