The effect of tranexamic acid during childbirth on maternal mortality: an epidemiological modelling and cost-effectiveness study

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BACKGROUND: Tranexamic acid reduces life-threatening bleeding after childbirth. We aimed to identify the settings where tranexamic acid cost-effectively reduces maternal deaths from bleeding. METHODS: We used WHO mortality data and effect estimates from our individual patient data meta-analysis to develop an epidemiological and cost-effectiveness model to calculate the absolute benefit (postpartum haemorrhage deaths averted) and potential harm (deaths from inadvertent intrathecal tranexamic acid injection) in each country, if all women received 1 g intravenous tranexamic acid when giving birth. We examined how benefits and harms vary by the risk of postpartum haemorrhage death to identify where the benefits outweigh the possible harms. We assessed cost-effectiveness using tranexamic acid costs and country's ability-to-pay estimates. FINDINGS: Giving tranexamic acid to all women giving birth reduced mortality in countries where the risk of postpartum haemorrhage death was five or more deaths per 100 000 births. Considering the average opportunity costs of treatment, tranexamic acid was cost-effective when the risk of postpartum haemorrhage death was 20 or more deaths per 100 000 births. However, due to variability in the ability to pay, tranexamic acid might not be cost-effective in 73% of countries with 20 or more postpartum haemorrhage deaths per 100 000 births. INTERPRETATION: Giving tranexamic acid to all women giving birth would reduce maternal deaths in Africa, south Asia, southeast Asia, and central and southern America, where most postpartum haemorrhage deaths occur. However, because these are regions with low ability to pay, even this highly effective treatment might not be cost-effective. Tranexamic acid must be made available and affordable in these settings. In high-income countries where risk of postpartum haemorrhage death is very low, the balance of risks and benefits is uncertain and further research is needed. FUNDING: The Gates Foundation.