Restrictive vs. liberal blood transfusion strategies in Africa: clinical outcomes, resource stewardship, and future directions.

Blood transfusion continues to be a vital part of contemporary healthcare, especially in treating severe anemia, bleeding, trauma, obstetric crises, and critical conditions. In Africa, where transfusion-dependent conditions are prevalent and blood supplies often limited, establishing the best transfusion threshold is crucial for enhancing patient outcomes while maximizing the use of scarce resources. Restrictive transfusion practices that typically use lower hemoglobin thresholds (7-8 g/dL) are now widely accepted globally as they minimize unnecessary transfusions while maintaining safety across various clinical environments. In contrast, liberal approaches, defined by elevated transfusion thresholds (9-10 g/dL), might still be suitable for specific patient groups, such as individuals with acute coronary syndromes, persistent significant bleeding, or serious symptomatic anemia. This review analyzes the existing evidence regarding restrictive vs. liberal blood transfusion strategies in the African context, focusing on clinical outcomes, resource management in healthcare, and prospective avenues for practice and investigation. Research from randomized controlled trials, observational studies, and global guidelines consistently shows that restrictive transfusion strategies correlate with similar mortality, morbidity, hospital stay duration, and functional recovery in most stable hospitalized patients, while minimizing transfusion-related complications and preserving limited blood resources. Nevertheless, the direct relevance of evidence produced mainly in high-income countries needs thorough evaluation due to Africa's distinct epidemiological characteristics, healthcare system constraints, and blood service deficiencies. Enhancing patient blood management initiatives, increasing voluntary blood donations, improving transfusion oversight, and producing robust African clinical evidence are essential priorities.