Clinical experiences with the use of oxytocin injection by healthcare providers in a southwestern state of Nigeria: A cross-sectional study

Patterns of oxytocin use for induction and augmentation of labour among healthcare providers in Nigeria

BACKGROUND

The practice of intrapartum use of oxytocin for induction and augmentation of labour is increasing worldwide with documented wide variations in clinical use, especially dose administrations. There is also evidence of intrapartum use by unauthorized cadre of staff.

AIM

This study assessed the patterns - frequency of intrapartum use of oxytocin, the doses and routes of administration for induction and augmentation of labour, and identified the predictors of oxytocin use for induction and augmentation of labour by healthcare providers in Nigeria.

METHODS

This was a cross-sectional study conducted among healthcare providers - doctors, nurses/midwives and community health workers (CHWs) in public and private healthcare facilities across the country's six geopolitical zones. A multistage sampling technique was used to select 6,299 eligible healthcare providers who use oxytocin for pregnant women during labour and delivery. A self-administered questionnaire was used to collect relevant data and analysed using STATA 17 statistical software. Summary and inferential statistics were done and further analyses using multivariable regression models were performed to ascertain independent predictor variables of correct patterns of intrapartum oxytocin usage. The p-value was set at < 0.05.

RESULTS

Of the 6299 respondents who participated in the study, 1179 (18.7%), 3362 (53.4%), and 1758 (27.9%) were doctors, nurses/midwives and CHWs, respectively. Among the respondents, 4200 (66.7%) use oxytocin for augmentation of labour while 3314 (52.6%) use it for induction of labour. Of the 1758 CHWs, 37.8% and 49% use oxytocin for induction and augmentation of labour, respectively. About 10% of the respondents who use oxytocin for the induction or augmentation of labour incorrectly use the intramuscular route of administration and about 8% incorrectly use intravenous push. Being a doctor, and a healthcare provider from government health facilities were independent positive predictors of the administration of correct dose oxytocin for induction and augmentation of labour. The CHWs were most likely to use the wrong route and dose administration of oxytocin for the induction and augmentation of labour.

CONCLUSION

Our study unveiled a concerning clinical practice of intrapartum oxytocin use by healthcare providers in Nigeria - prevalence of intrapartum use of oxytocin, inappropriate routes of administration for induction and augmentation of labour, varied and inappropriately high start dose of administration including unauthorized and high intrapartum use of oxytocin among CHWs.

What do healthcare providers think of the quality of uterotonics? A mixed-methods systematic review

OBJECTIVES

To synthesise evidence on the perceptions of healthcare providers (HCPs) about the quality of oxytocin and misoprostol available in their settings, and their actions as a result of these perceptions.

DESIGN

Mixed-methods systematic review.

ELIGIBILITY CRITERIA

We included quantitative and qualitative studies reporting HCPs' perceptions about oxytocin or misoprostol quality.

DATA SOURCES

We searched CINAHL, Cochrane Library, Ebscohost, Embase, PubMed, Global Index Medicus, Portal regional BVS, PsycNET, Scopus and Web of Science from inception to 31 March 2022 and grey literature.

RISK OF BIAS

We used the Center for Evidence-Based Management critical appraisal tool for surveys. For qualitative studies, we used the Critical Appraisal Skills Programme tool.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers performed study selection, data extraction and quality assessment. We conducted separate quantitative and qualitative syntheses and integrated the evidence into a narrative synthesis (convergent segregated review design).

RESULTS

We included five (three quantitative and two qualitative) studies, of moderate or high quality, conducted in low-income and middle-income countries (LMICs). In the three quantitative studies (N=7065 participants), 8.2-21.3% of HCPs had experienced problems due to known/suspected low-quality oxytocin and 3.3% due to low-quality misoprostol. In the two qualitative studies, perception of oxytocin quality varied. In quantitative studies, when confronted with suspected/known low-quality oxytocin, 29-78% of HCPs would inform a supervisor, 62% would document this in writing, 45-54% would change to another drug and 5-37% would double the dose of oxytocin. Qualitative evidence suggests that many HCPs do not formally report suspected low-quality oxytocin or misoprostol, and use higher doses or additional uterotonics.

CONCLUSIONS

A proportion of HCPs from LMICs perceive oxytocin to be of low quality. There is very limited evidence on their perceptions about misoprostol. Many HCPs do not report suspected low-quality uterotonics but change to another medicine or double the dose of oxytocin.

PROSPERO REGISTRATION NUMBER

CRD42022323812.

Cost-effectiveness and budget impact of heat-stable carbetocin compared to oxytocin and misoprostol for the prevention of postpartum hemorrhage (PPH) in women giving birth in India

INTRODUCTION

Low- and middle-income countries (LMICs) are committed to achieving the Sustainable Development Goal 3.1 to reduce maternal mortality. The Ministry of Health and Family Welfare of India recommends prophylactic uterotonic administration to every woman following delivery to reduce the risk of postpartum hemorrhage (PPH), as PPH is the leading cause of maternal mortality in LMICs, including India. In 2018, the World Health Organization first recognized heat-stable carbetocin for PPH prevention. Governments are now considering its introduction into their public health systems.

METHODS

A decision-tree model was developed from the public healthcare system perspective to compare the value of heat-stable carbetocin versus oxytocin and misoprostol among women giving birth in public sector healthcare facilities in India. The model accounted for differences in PPH risk and costs based on mode of delivery and healthcare setting, as well as provider behavior to mitigate quality concerns of oxytocin. Model outcomes for each prophylactic uterotonic included the number of PPH events, DALYs due to PPH, deaths due to PPH, and direct medical care costs. The budget impact was estimated based on projected uterotonic uptake between 2022-2026.

RESULTS

Compared to oxytocin, heat-stable carbetocin avoided 5,468 additional PPH events, 5 deaths, and 244 DALYs per 100,000 births. Projected direct medical costs to the public healthcare system were lowered by US $171,700 (₹12.8 million; exchange rate of ₹74.65 = US$1 from 2 Feb 2022) per 100,000 births. Benefits were even greater when compared to misoprostol (7,032 fewer PPH events, 10 fewer deaths, 470 fewer DALYs, and $230,248 saved per 100,000 births). In the budget impact analysis, India's public health system is projected to save US$11.4 million (₹849 million) over the next five years if the market share for heat-stable carbetocin grows to 19% of prophylactic uterotonics administered.

CONCLUSIONS

Heat-stable carbetocin is expected to reduce the number of PPH events and deaths, avoid more DALYs, and reduce costs to the public healthcare system of India. Greater adoption of heat-stable carbetocin for the prevention of PPH could advance India's efforts to achieve its maternal health goals and increase efficiency of its public health spending.

A descriptive study of healthcare-providers' experiences with the use and quality of oxytocin for the prevention of post-partum hemorrhage in Nigeria: A nation-wide survey

Background

Oxytocin is recommended as an affordable and effective drug in the prevention of postpartum hemorrhage—one of the leading causes of maternal morbidity and mortality in low- and middle-income countries, however, there are concerns about its proper use and quality. This study builds on earlier work conducted in a South-Western state in Nigeria.

Objective

The study assessed the knowledge around oxytocin, usage, storage practices and perceived quality of oxytocin used by healthcare providers that directly administer oxytocin for the prevention of postpartum hemorrhage across Nigeria.

Methods

This was a descriptive cross-sectional study that surveyed a representative sample of 6,299 healthcare providers who offer obstetrics and gynecological services and recruited from 1,894 healthcare facilities in Public and Private sectors in 12 states across Nigeria. Data were collected using an electronic questionnaire, analyzed using SPSS, and presented in frequencies and percentages.

Results

Only forty-six percent of respondents (52.8% in private; 40.0% in public sector) had proper knowledge that oxytocin storage is in the refrigerator. Proper knowledge also varied by professional cadre, doctors (71.2%); nurses (46.6%); Community Health Workers (28.4%) and by years of experience, less than 10 years (51.4%); more than 10 years (40.8%). Only 34% of the respondents (41% in private and 27.5% in public sector) reported good practices that oxytocin is stored in the refrigerator in their facilities. Most healthcare providers used oxytocin for prevention of PPH (77.9%). Oxytocin was also used for augmentation (66.7%) and induction of labor (52.6%). Half of respondents used above the WHO-recommended oxytocin dose of 10IU for prevention of PPH. Twenty-three percent of respondents reported experiencing oxytocin failure in PPH prevention of whom, 54.3% changed to another uterotonic and 37.1% doubled the dose of oxytocin for their patients.

Conclusion

Our study findings should be used to establish clinical guidelines and trainings for healthcare providers to improve their knowledge and storage practices and use to safeguard the quality of these lifesaving medicines.

Stability of Oxytocin Preparations in Malawi and Rwanda: Stabilizing Effect of Chlorobutanol

Oxytocin is used for the prevention and treatment of postpartum hemorrhage, the leading cause of maternal mortality in low- and middle-income countries. Because of the high instability of oxytocin, most products are labeled for storage at 2–8°C. Some other products are on the market which are labeled for non-refrigerated storage, but independent evaluations of their stability hardly exist. In the present study, seven brands (nine batches) of oxytocin were purchased from wholesalers and medical stores in Malawi and Rwanda and investigated by accelerated stability testing according to the ICH/WHO guidelines. Two oxytocin brands approved by a stringent regulatory authority (SRA) or by the WHO Prequalification of Medicines program and purchased in Europe were used as comparison. All investigated brands which were either produced in countries with SRAs, or were WHO-prequalified products, were labeled for storage at 2–8°C, and all of them passed stability testing with very good results. Even exposure to 25°C or 30°C for several months hardly affected their oxytocin content. However, two other investigated brands were labeled for non-refrigerated storage, and both of them had been produced in countries without SRAs. These two preparations showed not higher but lower stability than the brands labeled for storage at 2–8°C, and, for both of them, noncompliance with pharmacopoeial specifications was found after accelerated stability testing. At 40°C, and in forced degradation studies at 80°C, chlorobutanol showed a remarkable stabilizing effect on oxytocin, which may deserve further investigation. The results of the present study support the policy “Buy Quality Oxytocin, Keep It Cool.”

Quality assurance systems of pharmaceutical distributors in low-income and middle-income countries: weaknesses and ways forward

INTRODUCTION

Access to quality-assured medicines is an essential prerequisite for universal health coverage, and pharmaceutical distributors play an important role to assure the quality of medicines along the supply chain.

METHODS

We retrospectively assessed the compliance with WHO quality standards, that is, the Model Quality Assurance System for Procurement Agencies (MQAS) or the good distribution practices (GDP), of a convenience sample of 75 public, private-for-profit and non-for-profit distributors, audited by QUAMED in 14 low-income and middle-income countries (LMICs) between 2017 and 2019. We calculated the compliance per quality assurance activity, and we defined the percentage of compliant distributors, that is, the percentage (%) of distributors with MQAS or GDP levels of >2 for each activity.

RESULTS

The distributors in our sample were mainly private for-profit (66/75). Only one MQAS-audited distributor out of 11 was found compliant with all MQAS-activities, while none out of 64 GDP-assessed distributors were found compliant with all GDP activities. The GDP-assessed distributors were generally less compliant with WHO standards than MQAS-audited distributors. Common weaknesses and strengths were observed. The activities with lowest compliance were quality control, and physical storage conditions, while those with highest compliance were warehouse organisation and stock control.

CONCLUSIONS

The quality systems of pharmaceutical distributors in LMICs remain weak. For preventing harm caused by poor-quality medicines, a comprehensive and stringent regulatory oversight should be urgently implemented; the WHO MQAS-standards and GDP-standards should be incorporated in national regulations; and reliable information on the quality systems of distributors (and manufacturers from which they buy) should be publicly available.

The Use of Oxytocin by Healthcare Professionals During Labor

Background

Oxytocin is widely used in perinatal medicine, but it can cause serious side effects. Health professionals should be familiar with the pharmacokinetics, dosing regimen, and fetal effects of oxytocin. This study aims to explore the use of oxytocin by healthcare professionals during labor.

Methods

This study was conducted in one medical faculty, one training and research hospital, one maternity hospital, and one private hospital in Adana, Turkey. The sample group included 107 participants. The data were gathered using a survey prepared in line with the literature. The survey was comprised of 30 questions. These questions concern the social demographic information of the participants, the knowledge and actual oxytocin use, and the views of the participants. The data were analyzed using descriptive statistics.

Results

The average age of the participants was 36.76 ± 8.70 years, the mean of working experience in the delivery room was 7.79 ± 7.73 years. 85.6% of the participants who answered the question of possible effects of oxytocin as contraction, 57.9% of the possible side effects as fetal distress. 69.2% of the participants stated that they applied oxytocin after dilution in a fluid while 47% stated that they applied it after dilution in fluid with 5% Dextrose. While 40% of the participants responded that they sometimes forgot to administer medication, 39.2% stated that they did not register medication in their survey responses.

Conclusion

It was determined that most of the participants answered the questions about the effect of oxytocin correctly, but they could not respond to all the side effects of oxytocin. It was found that most of the participants could not answer the storage conditions that are important for the effectiveness of the drug correctly. In addition, the importance level given to the principles of drug administration by the participants was generally found to be high.

Quality of medicines for life-threatening pregnancy complications in low- and middle-income countries: A systematic review

Background

There are concerns about the quality of medicines available in low- and middle-income countries (LMIC) to manage hemorrhage, pre-eclampsia/eclampsia and sepsis. We aimed to identify, critically appraise, and synthesize the findings of studies on the quality of these three types of medicines available in LMIC.

Methods

This systematic review searched Medline, EMBASE and LILACS (from inception to 25 May 2020) for studies on the quality of selected medicines available in LMIC that provided at least the amount of active pharmaceutical ingredient. We contacted study authors for additional information. We excluded simulation studies. We used the MEDQUARG tool to assess study quality. The main outcome was the prevalence of failed samples.

Findings

We identified 9699 unique citations and included 34 studies (3159 samples from 40 countries) in the review. Most studies (65%) had low quality (scores <6/12). Overall, 48.9% of 1890 uterotonic samples (19 studies) failed quality tests; failures rates were 75% for ergometrine and nearly 40% each for oxytocin and misoprostol. The overall prevalence of failed injectable antibiotics (1090 samples, 18 studies) was 13.4%, ranging from 2.9% for injectable metronidazole (34 samples, 3 studies) to 16.0% for cefazolin (449 samples, 2 studies). The prevalence of low quality magnesium sulphate (179 samples, 2 studies) was 3.4%. We did not find any studies on the quality of carbetocin, tranexamic acid, or clindamycin.

Conclusions

There is a widespread problem with the quality of medicines used to manage life-threatening maternal conditions in LMIC. This can be a contributing factor to high maternal mortality rates in these regions.