Oxytocin: taking the heat

Oxytocin quality: evidence to support updated global recommendations on oxytocin for postpartum hemorrhage

BACKGROUND

The use of quality injectable oxytocin effectively prevents and treats postpartum hemorrhage, the leading cause of maternal death worldwide. In low- and middle-income countries (LMICs), characteristics of oxytocin-specifically its heat sensitivity-challenge efforts to ensure its quality throughout the health supply chain. In 2019, WHO, UNFPA and UNICEF released a joint-statement to clarify and recommend that oxytocin should be kept in the cold chain (between 2 and 8 °C) during transportation and storage; however, confusion among stakeholders in LMICs persists.

OBJECTIVES AND METHODS

To further support recommendations in the WHO/UNFPA/UNICEF joint-statement, this paper reviews results of oxytocin quality testing in LMICs, evaluates product stability considerations for its management and considers quality risks for oxytocin injection throughout the health supply chain. This paper concludes with a set of recommended actions to address the challenges in maintaining quality for a heat sensitive pharmaceutical product.

RESULTS

Due to the heat sensitivity of oxytocin, its quality may be degraded at numerous points along the health supply chain including: At the point of manufacture, due to poor quality active pharmaceutical ingredients; lack of sterile manufacturing environments; or low-quality manufacturing processesDuring storage and distribution, due to lack of temperature control in the supply chain, including cold chain at the end user health facilitySafeguarding the quality of oxytocin falls under the purview of national medicines regulatory authorities; however, regulators in LMICs may not adhere to good regulatory practices.

CONCLUSIONS

Storing oxytocin from 2 to 8 °C throughout the supply chain is important for maintaining its quality. While short temperature excursions may not harm product quality, the cumulative heat exposure is generally not tracked and leads to degradation. National and sub-national policies must prioritize procurement of quality oxytocin and require its appropriate storage and management.

The Novelty of Inhalable Medications: Interest, Use, and Impact of Inhalant Medications in Low-Resource Settings

Introduction:

Postpartum haemorrhage (PPH) claims more than 100,000 maternal lives annually worldwide, most of them in low-resource settings. To address morbidity and mortality from PPH, the global health community is exploring novel drug formulations, such as inhalable medicine, to improve treatment availability and use, especially in community settings with limited access to skilled birth attendants. A major limitation in the ability to prevent or treat PPH in resource-limited settings is that the most effective medications for prevention and treatment are injectables, which require administration by skilled birth attendants.

Methodology:

We conducted formative research, including online surveys and in-person interviews, with a range of providers across a variety of health-care settings in Guatemala, Indonesia, Kenya, and Nigeria, to better understand the standard of care for mothers and newborns in low-resource settings, including care practices related to PPH.

Results:

It is estimated that up to 40% of PPH deaths could be averted if an inhalable prevention and treatment were available. However, survey and interview respondents noted a desire for more intravenous and oral medicinal formulations over inhalable formulations.

Discussion/Conclusion:

Lack of knowledge and use of inhalable medicines among these health workers illuminates key challenges to introducing novel formulations in low-resource settings.

Quality of oxytocin available in low- and middle-income countries: a systematic review of the literature

BACKGROUND

Oxytocin is the drug of choice for preventing and treating postpartum haemorrhage, an important cause of maternal death. Oxytocin is widely available in low and middle-income countries (LMIC) but there are concerns about its quality.

OBJECTIVE

To identify, critically appraise and synthesise the findings of studies on the quality of oxytocin available in LMIC.

SEARCH STRATEGY

We searched seven electronic databases, without language restriction.

SELECTION CRITERIA

Studies reporting results of tests to assess quality of oxytocin samples from LMIC.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction and quality assessment were performed in duplicate. Results are presented descriptively.

MAIN RESULTS

The search identified 2611 unique citations; eight studies, assessing 559 samples from 15 different countries were included. Most samples were collected from facility level settings (n = 509) and from the private sector (n = 321). The median prevalence of oxytocin samples that failed quality tests was 45.6% (range 0-80%), mostly due to insufficient amounts of active pharmacological ingredient. Over one-third of the samples (n = 204) had low (<90%) oxytocin content indicating substandard medicine; two samples had no active ingredient, suggesting possible counterfeit drugs. The proportion of low fails was higher in samples collected in Africa than in Asia or Latin America (57.5% versus 22.3% versus 0%, respectively, P < 0.0001), in private than in public sectors (34.0% versus 25.3%, P = 0.032) and in facilities than in central distributors (37.9% versus 22.0%, P = 0.030).

CONCLUSION

There is a high prevalence of poor-quality oxytocin samples in LMIC countries, mainly due to inadequate amounts of active ingredient.

TWEETABLE ABSTRACT

Systematic review points to problems with quality of oxytocin samples from low- and middle-income countries.

Transformative Innovations in Reproductive, Maternal, Newborn, and Child Health over the Next 20 Years

As part of the "Grand Convergence: Aligning Technologies and Realities in Global Health" Collection, Cyril Engmann and colleagues discuss promising innovations that have the potential to move the RMNCH agenda forward.