Implementation of new WHO postpartum haemorrhage diagnostic criteria in routine care: a multi-country mixed-methods study

Abstract

Background Postpartum haemorrhage is a leading cause of maternal death globally. To support earlier diagnosis and treatment of the condition, in 2025, WHO introduced new diagnostic criteria based on objectively measured blood loss of 300 mL or more with any abnormal haemodynamic sign, or 500 mL or more, whichever occurs first within 24 h after birth. Our study aimed to assess the feasibility, fidelity, acceptability, clinical outcomes, management practices, and cost implications of applying the new criteria. Methods We conducted a prospective, multi-country, mixed-methods study in 18 primary, secondary, and tertiary facilities across Colombia, India, Kenya, Nigeria, Tanzania, and Thailand between July 24 and Oct 1, 2025. Eligible health workers received training on the diagnostic criteria and postpartum haemorrhage first-response treatment bundle. Observers prospectively recorded blood loss, haemodynamic signs, postpartum haemorrhage diagnoses, and treatments for all births over 5 consecutive weeks. Health workers completed pre-training and post-implementation surveys and participated in semi-structured interviews. Descriptive statistics were used for quantitative data and mean-unit-cost per woman was estimated. Quantitative and qualitative findings were integrated to generate triangulated inferences. Findings 5264 births were observed across the 18 participating facilities during the 5-week implementation period. 33·2% of births occurred in India, 20·4% in Tanzania, 16·3% in Kenya, 11·6% in Nigeria, 9·9% in Colombia, and 8·5% in Thailand. More than half (53·2%) of all births took place in tertiary-level facilities, 31·9% in secondary-level facilities, and 15·0% in primary care facilities. Objective blood loss volume and at least one postpartum clinical assessment were recorded for 82·8% (4361 of 5264) of births during the study period. Health workers considered the new criteria feasible (97·6%; 528 of 541) and acceptable (96·8%; 338 of 349). Overall incidence of postpartum haemorrhage was 20·8% (908 of 4361) using the new criteria compared with 14·7% (701 of 4760) using the conventional 500 mL or more threshold. Postpartum haemorrhage incidence with the new criteria was more than double for caesarean (30·7%; 560 of 1823) compared with vaginal birth (13·7%; 348 of 2538). During the 5-week implementation period, overall adherence with the new diagnostic criteria was 54·1% (491 of 908) but was much higher for vaginal (85·6%; 298 of 348) than caesarean births (34·5%; 193 of 560). All women diagnosed with postpartum haemorrhage received treatment. The additional weighted mean cost per woman treated was US$4·6 (range 1·9–8·9) while mean cost of escalating care was $70·1 with great variation based on countries' practices (4·0–307·9). Health workers emphasised the need for reliable supply chains, strong leadership, and national procurement mechanisms to ensure that the criteria are consistently applied. Interpretation In routine clinical care settings, implementing the new postpartum haemorrhage diagnostic criteria was feasible and acceptable, and increased early diagnosis with modest additional treatment costs. Adherence observed in the short term suggests meaningful uptake although strengthened implementation processes, particularly for caesarean births, will be required to support sustained use and scale-up. Funding The Gates Foundation and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, a co-sponsored programme executed by WHO.