[National confidential enquiry into maternal deaths in France, a 25-year enhanced surveillance system, essential for the reliable characterization of maternal deaths]. / Enquête Nationale Confidentielle sur les Morts Maternelles en France, un système de surveillance améliorée depuis 25 ans, indispensable pour la caractérisation fiable des décès maternels.

Although maternal mortality is rare in wealthy countries, it remains a fundamental indicator of maternal health. It is considered to be a "sentinel event", the occurrence of which indicates dysfunctions, often cumulative, in the healthcare system. In addition to the classic epidemiological surveillance findings - number of deaths, maternal mortality ratio, distribution of medical causes, sub-groups of women at risk - its study, through a precise analysis of the history of each woman who died, enables to highlight areas for improvement in the content or organisation of care, the correction of which will make it possible to prevent not only deaths but also upstream morbid events involving the same mechanisms. To achieve this dual epidemiological and clinical audit objective, an ad hoc "enhanced" system is needed. France has had such a system since 1996, the Enquête Nationale Confidentielle sur la Mortalité Maternelle (ENCMM), under the joint supervision of Santé Publique France and Inserm. The ENCMM method aims to identify maternal deaths exhaustively and reliably up to 1 year after the end of pregnancy, and to document each death as fully as possible. The 1st step is the multi-source identification (direct declaration, death certificates, linkage with birth certificates, hospital stay database) of women who died during pregnancy or in the year following its end. The 2nd step is the collection of detailed information for each death by a pair of clinical assessors. The 3rd step is the review of these anonymised documents by the National Expert Committee on Maternal Mortality, which establishes the maternal nature of the death (causal link with pregnancy) and, with a stated aim of improvement rather than judgement, assesses the adequacy of care and the preventability of the death. The summary of the information gathered for maternal deaths in the 2016-2018 period is presented in the other articles of this special issue.

[Maternal mortality due to venous thromboembolism in France 2016-2018]. / Mortalité maternelle par thromboembolie veineuse en France 2016­2018.

Pregnancy and the post-partum period represent a thromboembolic risk situation, with pulmonary embolism (PE) remaining one of the leading causes of direct maternal deaths in developed countries. Between 2016 and 2018 in France, twenty maternal deaths were caused by venous thromboembolic complications (VTE), yielding a Maternal Mortality Ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3), with no change compared to the periods 2013-2015 or 2010-2012. Among these 20 deaths, 1 death was related to cerebral thrombophlebitis, and the remaining 19 were due to PE. Regarding the timing of death, 2 deaths occurred after an early termination of pregnancy, 40% (8/20) during an ongoing pregnancy, and 50% (10/20) in the post-partum period. Among the 20 VTE deaths, 20% (4/20) occurred outside of a healthcare facility (at home or in a public place). Among the nineteen cases with documented BMI, seven women had obesity (37%), three times more than in the population of parturients in France (11.8%, ENP 2016). Among the nineteen PE deaths and the case of cerebral thrombophlebitis, eleven were considered preventable, six possibly preventable (35%), two probably preventable (12%), and three preventability undetermined. The identified preventability factors were inadequate care and the patient's failure to interact with the healthcare system. From the case analysis, areas for improvement were identified, including insufficient consideration of major and minor risk factors, the early initiation of appropriate prophylactic treatment, and the absence of fibrinolysis in cases of s refractory cardiac arrest due to suspected PE.

Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique.

BACKGROUND: The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance. METHODS: The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial. RESULTS: Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care. CONCLUSIONS: There is a need to supplement the pioneering "Three Delays Framework" to include focusing on continuity of care and the "Four Critical Connection Points": (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys. TRIAL REGISTRATION: NCT01911494, Date Registered 30/07/2013.

Confidential Enquiry into Maternal Deaths in Namibia, 2018-2019: A Local Approach to Strengthen the Review Process and a Description of Review Findings and Recommendations.

OBJECTIVES: First objective was to strengthen the national maternal death review, by addressing local challenges with each step of the review cycle. Second objective was to describe review findings and compare these with available findings of previous reviews. METHODS: Confidential Enquiry into Maternal Deaths methodology was used to review maternal deaths. To improve reporting, the national committee focussed on addressing fear of blame among healthcare providers. Second focus was on dissemination of findings and acting on recommendations forthcoming the review. Reviewed were reported maternal deaths, that occurred between 1 April 2018 and 31 March 2019. RESULTS: Seventy maternal deaths were reported; for 69 (98.6%) medical records were available, compared to 80/119 (67.2%) in 2012-2015. Reported maternal mortality ratio increased with 48% (92/100,000 live births compared to 62/100,000 in 2012-2015). Obstetric haemorrhage was leading cause of death in the past three reviews. The "no name, no blame" policy, aiming to identify health system failures, rather than mistakes of individuals, was repeatedly explained to healthcare providers during facility visits. Recommendations based on findings of the review, such as retaining experienced staff, continuous in-service training and guidance, were shared with decision makers at regional and national levels. Healthcare providers received training based on review findings, which resulted in improved management of similar cases. CONCLUSIONS FOR PRACTICE: Enhanced implementation of Confidential Enquiry into Maternal Deaths was possible after addressing local challenges. Focussing on obtaining trust of healthcare providers and feeding back findings, resulted in better reporting and prevention of potential maternal deaths.

Acting fast to prevent post-partum deaths.

A new approach to treating post-partum haemorrhage is having a substantial impact on maternal deaths. Tatum Anderson reports.

CRADLE-5: a stepped-wedge type 2 hybrid implementation-effectiveness cluster randomised controlled trial to evaluate the real-world scale-up of the CRADLE Vital Signs Alert intervention into routine maternity care in Sierra Leone-study protocol.

BACKGROUND: The CRADLE Vital Signs Alert intervention (an accurate easy-to-use device that measures blood pressure and pulse with inbuilt traffic-light early warning system, and focused training package) was associated with reduced rates of eclampsia and maternal death when trialled in urban areas in Sierra Leone. Subsequently, implementation was successfully piloted as evidenced by measures of fidelity, feasibility and adoption. The CRADLE-5 trial will examine whether national scale-up, including in the most rural areas, will reduce a composite outcome of maternal and fetal mortality and maternal morbidity and will evaluate how the CRADLE package can be embedded sustainably into routine clinical pathways. METHODS: CRADLE-5 is a stepped-wedge cluster-randomised controlled trial of the CRADLE intervention compared to routine maternity care across eight rural districts in Sierra Leone (Bonthe, Falaba, Karene, Kailahun, Koinadugu, Kono, Moyamba, Tonkolili). Each district will cross from control to intervention at six-weekly intervals over the course of 1 year (May 2022 to June 2023). All women identified as pregnant or within six-weeks postpartum presenting for maternity care in the district are included. Primary outcome data (composite rate of maternal death, stillbirth, eclampsia and emergency hysterectomy) will be collected. A mixed-methods process and scale-up evaluation (informed by Medical Research Council guidance for complex interventions and the World Health Organization ExpandNet tools) will explore implementation outcomes of fidelity, adoption, adaptation and scale-up outcomes of reach, maintenance, sustainability and integration. Mechanisms of change and contextual factors (barriers and facilitators) will be assessed. A concurrent cost-effectiveness analysis will be undertaken. DISCUSSION: International guidance recommends that all pregnant and postpartum women have regular blood pressure assessment, and healthcare staff are adequately trained to respond to abnormalities. Clinical effectiveness to improve maternal and perinatal health in more rural areas, and ease of integration and sustainability of the CRADLE intervention at scale has yet to be investigated. This trial will explore whether national scale-up of the CRADLE intervention reduces maternal and fetal mortality and severe maternal adverse outcomes and understand the strategies for adoption, integration and sustainability in low-resource settings. If successful, the aim is to develop an adaptable, evidence-based scale-up roadmap to improve maternal and infant outcomes. TRIAL REGISTRATION: ISRCTN 94429427. Registered on 20 April 2022.

Activities of the Japan Council for Implementation of the Maternal Emergency Life Support System reduced direct causes of maternal deaths in Japan.

Here, we aimed to provide an overview of Japan Council for the Implementation of the Maternal Emergency Life-Saving System (J-CIMELS) and its simulation program, which has reduced maternal mortality due to direct causes in Japan. The Japan Association of Obstetricians and Gynecologists (JAOG), Japan Association of Obstetricians and Gynecologists, and Maternal Death Exploratory Committee (JMDEC) launched the Maternal Death Reporting Project in 2010. The project analyzed obstetricians' tendency to delay their initial response to sudden maternal deterioration. Obstetricians can predict small changes before deterioration by monitoring vital signs. In 2015, the J-CIMELS was established to provide practical education. J-CIMELS developed a simulation program (J-MELS; Japan Maternal Emergency Life Support) to ensure that the obstetricians acquire the latest knowledge of emergency physicians, anesthesiologists, and other general practitioners and apply it in clinical situations. In the last 7 years, the J-MELS basic course has been conducted 1000 times with a total attendance of 19 890 people. As a result, the incidence of obstetric hemorrhage progressively decreased from 29% in 2010 to 7% in 2020. We believe that the activities of J-CIMELS are improving obstetric care providers' medical practices in Japan.

Timing and Preventability of Cardiovascular-Related Maternal Death.

OBJECTIVE: To describe the clinical profile, management, and potential preventability of maternal cardiovascular deaths. METHODS: We conducted a retrospective, descriptive study of all maternal deaths resulting from a cardiovascular disease during pregnancy or up to 1 year after the end of pregnancy in France from 2007 to 2015. Deaths were identified through the nationwide permanent enhanced maternal mortality surveillance system (ENCMM [Enquête Nationale Confidentielle sur les Morts Maternelles]). Women were classified into four groups based on the assessment of the national experts committee: those who died of a cardiac condition and those who died of a vascular condition and, within these two groups, whether the condition was known before the acute event. Maternal characteristics, clinical features and components of suboptimal care, and preventability factors, which were assessed with a standard evaluation form, were described among those four groups. RESULTS: During the 9-year period, 103 women died of cardiac or vascular disease, which corresponds to a maternal mortality ratio from these conditions of 1.4 per 100,000 live births (95% CI 1.1-1.7). Analyses were conducted on 93 maternal deaths resulting from cardiac (n=70) and vascular (n=23) disease with available data from confidential inquiry. More than two thirds of these deaths occurred in women with no known pre-existing cardiac or vascular condition. Among the 70 deaths resulting from a cardiac condition, 60.7% were preventable, and the main preventability factor was a lack of multidisciplinary prepregnancy and prenatal care for women with a known cardiac disease. For those with no known pre-existing cardiac condition, preventability factors were related mostly to inadequate prehospital care of the acute event, in particular an underestimation of the severity and inadequate investigation of the dyspnea. Among the 23 women who died of a vascular disease, three had previously known conditions. For women with no previously known vascular condition, 47.4% of deaths were preventable, and preventability factors were related mostly to wrong or delayed diagnosis and management of acute intense chest or abdominal pain in a pregnant woman. CONCLUSION: Most maternal deaths attributable to cardiac or vascular diseases were potentially preventable. The preventability factors varied according to the cardiac or vascular site and whether the condition was known before pregnancy. A more granular understanding of the cause and related risk factors for maternal mortality is crucial to identify relevant opportunities for improving care and training health care professionals.

Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different context of care.

OBJECTIVE: To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. METHODS: In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. RESULTS: For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. CONCLUSION: A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.

Levels, trends, causes, place and time of, care-seeking for, and barriers in preventing indirect maternal deaths in Bangladesh: An analysis of national-level household surveys.

Background: Eclampsia, haemorrhage, and other direct causes are the primary burden of maternal mortality in Bangladesh, often reducing attention given to indirect maternal deaths (IMDs). However, Sustainable Development Goals may not be achieved without actions to prevent IMDs. We examined the levels, trends, specific causes, timing, place, and care-seeking, and explored the barriers to IMD prevention. Methods: We used three nationally representative surveys conducted in 2001, 2010, and 2016 to examine levels and trends in IMDs. The analysis of specific causes, timing, and place of IMDs, and care-seeking before the deaths was based on 37 IMDs captured in the 2016 survey. Finally, we used thematic content analysis of the open history from the 2016 survey verbal autopsy (VA) questionnaire to explore barriers to IMD prevention. Results: After increasing from 51 deaths per 100 000 live births in 2001 to 71 in 2010, the indirect maternal mortality ratio (IMMR) dropped to 38 deaths per 100 000 live births in 2016. In 2016, the indirect causes shared one-fifth of the maternal deaths in Bangladesh. Stroke, cancer, heart disease, and asthma accounted for 80% of the IMDs. IMDs were concentrated in the first trimester of pregnancy (27%) and day 8-42 after delivery (32%). Public health facilities were the main places for care-seeking (48%) and death (49%). Thirty-four (92%) women who died from IMDs sought care from a health facility at least once during their terminal illness. However, most women experienced at least one of the "three delays" of health care. Other barriers were financial insolvency, care-seeking from unqualified providers, lack of health counselling, and the tendency of health facilities to avoid responsibilities. Conclusions: IMMR remained unchanged at a high level during the last two decades. The high concentration of IMDs in pregnancy and the large share due to chronic health conditions indicate the need for preconception health check-ups. Awareness of maternal complications, proper care-seeking, and healthy reproductive practices may benefit. Improving regular and emergency maternal service readiness is essential.

Maternal mortality is preventable in Lebanon: A case series of maternal deaths to identify lessons learned using the "Three Delays" model.

OBJECTIVE: To identify the lessons learned from women who died during pregnancy or childbirth in Lebanon between 2018 and 2020. METHOD: This is a case series and synthesis of maternal deaths between 2018 and 2020 that were reported by healthcare facilities to the Ministry of Public Health in Lebanon. The notes recorded from the maternal mortality review reports were analyzed using the "Three Delays" model to identify preventable causes and lessons learned. RESULTS: A total of 49 women died before, during, or after childbirth, with hemorrhage being the most frequent cause (n = 16). The possible factors that would have prevented maternal deaths included a prompt recognition of clinical severity, availability of blood for transfusion and magnesium sulfate for eclampsia, adequate transfer to tertiary care hospitals comprising specialist care, and involvement of skilled medical staff in obstetric emergencies. CONCLUSION: Many maternal deaths in Lebanon are preventable. Better risk assessment, use of an obstetric warning system, access to adequately skilled human resources and medications, and improved communication and transfer mechanisms between private and tertiary care hospitals may avoid future maternal deaths.

A qualitative evaluation and conceptual framework on the use of the Birth weight and Age-at-death Boxes for Intervention and Evaluation System (BABIES) matrix for perinatal health in Uganda.

BACKGROUND: Perinatal mortality (newborn deaths in the first week of life and stillbirths) continues to be a significant global health threat, particularly in resource-constrained settings. Low-tech, innovative solutions that close the quality-of-care gap may contribute to progress toward the Sustainable Development Goals for health by 2030. From 2012 to 2018, the Saving Mothers, Giving Life Initiative (SMGL) implemented the Birth weight and Age-at-Death Boxes for Intervention and Evaluation System (BABIES) matrix in Western Uganda. The BABIES matrix provides a simple, standardized way to track perinatal health outcomes to inform evidence-based quality improvement strategies. METHODS: In November 2017, a facility-based qualitative evaluation was conducted using in-depth interviews with 29 health workers in 16 health facilities implementing BABIES in Uganda. Data were analyzed using directed content analysis across five domains: 1) perceived ease of use, 2) how the matrix was used, 3) changes in behavior or standard operating procedures after introduction, 4) perceived value of the matrix, and 5) program sustainability. RESULTS: Values in the matrix were easy to calculate, but training was required to ensure correct data placement and interpretation. Displaying the matrix on a highly visible board in the maternity ward fostered a sense of accountability for health outcomes. BABIES matrix reports were compiled, reviewed, and responded to monthly by interprofessional teams, prompting collaboration across units to fill data gaps and support perinatal death reviews. Respondents reported improved staff communication and performance appraisal, community engagement, and ability to track and link clinical outcomes with actions. Midwives felt empowered to participate in the problem-solving process. Respondents were motivated to continue using BABIES, although sustainability concerns were raised due to funding and staff shortages. CONCLUSIONS: District-level health systems can use data compiled from the BABIES matrix to inform policy and guide implementation of community-centered health practices to improve perinatal heath. Future work may consider using the Conceptual Framework on Use of the BABIES Matrix for Perinatal Health as a model to operationalize concepts and test the impact of the tool over time.

Maternal and perinatal death surveillance and response: a systematic review of qualitative studies.

Objective: To understand the experiences and perceptions of people implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries, and the mechanisms by which this process can achieve its intended outcomes. Methods: In June 2022, we systematically searched seven databases for qualitative studies of stakeholders implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries. Two reviewers independently screened articles and assessed their quality. We used thematic synthesis to derive descriptive themes and a realist approach to understand the context-mechanism-outcome configurations. Findings: Fifty-nine studies met the inclusion criteria. Good outcomes (improved quality of care or reduced mortality) were underpinned by a functional action cycle. Mechanisms for effective death surveillance and response included learning, vigilance and implementation of recommendations which motivated further engagement. The key context to enable effective death surveillance and response was a blame-free learning environment with good leadership. Inadequate outcomes (lack of improvement in care and mortality and discontinuation of death surveillance and response) resulted from a vicious cycle of under-reporting, inaccurate data, and inadequate review and recommendations, which led to demotivation and disengagement. Some harmful outcomes were reported, such as inappropriate referrals and worsened staff shortages, which resulted from a fear of negative consequences, including blame, disciplinary action or litigation. Conclusion: Conditions needed for effective maternal and/or perinatal death surveillance and response include: separation of the process from litigation and disciplinary procedures; comprehensive guidelines and training; adequate resources to implement recommendations; and supportive supervision to enable safe learning.

Why maternal mortality in the world remains tragedy in low-income countries and shame for high-income ones: will sustainable development goals (SDG) help?

Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management. Maternal mortality (MM) and morbidity are a public health issue, with scarce knowledge on their levels and causes in low-income (LIC) countries. The data on MM and morbidity should rely on population-based studies which are non-existent. Therefore, maternal mortality ratio (MMR) estimates are based mostly on the mathematical models. MMR declined from 430 per 100,000 live births (LB) in 1990 to 211 in 2017. Absolute numbers of maternal deaths were 585,000 in 1990, 514,500 in 1995 and less than 300,000 nowadays. Regardless of reduction, MM remains neglected tragedy especially in LIC. Millennium Development Goals (MDGs) declared reduction MMR by three quarters between 2000 and 2015, which failed. Target of Sustainable Development Goals (SDGs) was to decrease MMR to 70 per 100,000 LB. Based on the data from the country report on SDGs in 10 countries with the highest absolute number of maternal deaths it can be concluded that the progress has not been made in reaching the targeted MMR. To reduce MMR, inequalities in access to and quality of reproductive, maternal, and newborn health care services should be addressed, together with strengthening health systems to respond to the needs and priorities of women and girls, ensuring accountability to improve quality of care and equity.

Maternal mortality related to pulmonary embolism in the United States, 2003-2020.

BACKGROUND: Pulmonary embolism is a leading cause of maternal morbidity and mortality in Western countries. In the United States, pulmonary embolism-related mortality rates have plateaued in the general population after an initial decrease in the past 20 years. OBJECTIVE: This study aimed to describe the changes in pulmonary embolism-related maternal mortality rates in the United States over the past 2 decades. STUDY DESIGN: In this epidemiologic study of public vital registration data (death certificates encompassing underlying and contributing causes of death) from the Centers for Disease Control and Prevention Multiple Cause of Death database (2003-2020), we identified all maternal deaths with a pulmonary embolism code listed in any position of the death certificates. We investigated the changes in annual crude pulmonary embolism-related maternal mortality rates for the years 2003 to 2020, considering the effect of the introduction of the pregnancy checkbox in death certificates on the pulmonary embolism-related maternal mortality rates. RESULTS: Overall, 735 pulmonary embolism-related maternal deaths out of 12,871 total maternal deaths (5.7%) were recorded between 2003 and 2020; the overall pulmonary embolism-related maternal mortality rate was 1.02 (95% confidence interval, 0.95-1.10) per 100,000 live births. The pulmonary embolism-related maternal mortality rate increased from 0.93 in 2003 to 1.96 in 2020; however, when accounting for the implementation of the pregnancy checkbox in the death certificates, the trends in pulmonary embolism-related maternal mortality were largely unchanged from 2003 to 2020. The crude pulmonary embolism-related maternal mortality rates differed across maternal age groups (overall 0.61, 1.09, and 3.83 maternal deaths per 100,000 live births for those aged ≤24, 25-39, and ≥40 years, respectively) and racial/ethnicity groups (2.89, 0.47, 0.77, and 0.63 maternal deaths per 100,000 live births for Black non-Hispanics, other non-Hispanics, White non-Hispanics, and Hispanics, respectively). CONCLUSION: Maternal mortality rates related to pulmonary embolism did not decrease during the period from 2003 to 2020, as opposed to mortality rates related to pulmonary embolism in the general population. More research is required to assess whether improvement in venous thromboembolism prevention and pulmonary embolism diagnosis and management strategies might reduce death owing to pulmonary embolism in this vulnerable population.

Cost-effectiveness analysis of carbetocin for prevention of postpartum hemorrhage in a low-burden high-resource city of China.

BACKGROUND: Postpartum hemorrhage (PPH) is a major cause of maternal morbidity, and oxytocin is the first-line uterotonic agent for PPH prevention. Clinical findings have reported carbetocin to reduce PPH risk without increasing risk of important side effects. Hong Kong is a low PPH burden and high-resource city in China. We aimed to examine the cost-effectiveness of PPH prevention with carbetocin from the perspective of Hong Kong public healthcare provider. METHODS: A decision-analytic model was developed to simulate clinical and economic outcomes of carbetocin and oxytocin for PPH prevention in a hypothetical cohort of women at the third stage of labor following vaginal birth or Caesarean section (C-section). The model inputs were retrieved from literature and public data. Base-case analysis and sensitivity analysis were performed. The model time horizon was the postpartum hospitalization period. Primary model outcomes included PPH-related direct medical cost, PPH, hysterectomy, maternal death, and quality-adjusted life-year (QALY) loss. RESULTS: In base-case analysis, carbetocin (versus oxytocin) reduced PPH-related cost (by USD29 per birth), PPH ≥500 mL and ≥1,500 mL (by 13.7 and 1.9 per 1,000 births), hysterectomy (by 0.15 per 1,000 births), maternal death (by 0.02 per 1,000 births), and saved 0.00059 QALY per birth. Relative risk of PPH ≥500 mL with carbetocin versus oxytocin, and proportion of child births by C-section were two influential parameters identified in deterministic sensitivity analysis. In probabilistic sensitivity analysis, carbetocin was accepted as cost-effective in >99.7% of the 10,000 Monte Carlo simulations at a willingness-to-pay threshold of zero USD/QALY. CONCLUSION: PPH prevention with carbetocin appeared to reduce major unfavorable outcomes, and save cost and QALYs.