Knowledge, perception and practice towards oxytocin stability and quality: A qualitative study of stakeholders in three resource-limited countries

Abstract

BackgroundOxytocin is the gold standard drug for the prevention of postpartum haemorrhage, but limitations in cold chain systems in resource-constrained settings can severely compromise the quality of oxytocin product available in these environments. This study investigated the perspectives and practices of stakeholders in low and lower-middle income countries towards oxytocin, its storage requirements and associated barriers, and the quality of product available.MethodsQualitative inquiries were undertaken in Ethiopia, India and Myanmar, where data was collected through Focus Group Discussions (FGDs) and In-Depth Interviews (IDIs). A total of 12 FGDs and 106 IDIs were conducted with 158 healthcare providers (pharmacists, midwives, nurses, doctors and obstetricians) and 40 key informants (supply chain experts, program managers and policy-makers). Direct observations of oxytocin storage practices and cold chain resources were conducted at 51 healthcare facilities. Verbatim transcripts of FGDs and IDIs were translated to English and analysed according to a thematic content analysis framework.FindingsStakeholder awareness of oxytocin heat sensitivity and the requirement for cold storage of the drug was widespread in Ethiopia but more limited in Myanmar and India. A consistent finding across all study regions was the significant barriers to maintaining a consistent cold chain, with the lack of refrigeration facilities and unreliability of electricity cited as major challenges. Perceptions of compromised oxytocin quality were expressed by some stakeholders in each country.ConclusionKnowledge of the heat sensitivity of oxytocin and the potential impacts of inconsistent cold storage on product quality is not widespread amongst healthcare providers, policy makers and supply chain experts in Myanmar, Ethiopia and India. Targeted training and advocacy messages are warranted to emphasise the importance of cold storage to maintain oxytocin quality.

Post-Partum Hemorrhage is Still Killing Mothers in Bangladesh: An Observation from the 2016 Bangladesh Maternal Mortality Survey (BMMS)

“…The data also indicate that oxytocin use is suboptimal with issues of availability and, potentially, potency. Unfortunately, in Bangladesh there is no formal guideline on the use and storage of oxytocin in the public and private sector [7,8]. The Directorate General of Health Services Bangladesh issued a circular in 2012 for the proper use of oxytocin in health facilities but this has not been institutionalized [5,9].…”

Factors affecting the prevention of postpartum hemorrhage in Low- and Middle-Income Countries: A scoping review of the literature

“…The analysis found evidence that Injectable Oxytocin (10 IU administered intramuscularly or intravenously) stands for the uterotonic of first choice for all births, but entails transport to be stored at temperature between 2 • C-8 • C. [38] A qualitative inquiry carried out in Ethiopia, India and Myanmar investigated the perspectives and practices of stakeholders towards oxytocin, the requirements for storage and barriers associated , as well as the quality of available product. [50] The study found that in Ethiopia, healthcare providers were aware that it is required that oxytocin should be kept refrigerated, and knew that the product is likely to lose its efficacy once not refrigerated. However, in Myanmar, it was noticed that Oxytocin was stored at room temperature in the labor wards in roughly thirty percent of the health facilities where data collection was conducted.…”

“…However, in Myanmar, it was noticed that Oxytocin was stored at room temperature in the labor wards in roughly thirty percent of the health facilities where data collection was conducted. [50] Similarly, in India knowledge of oxytocin storage requirements was shared among the health providers, and was frequently limited to medical doctors and obstetricians/gynecologists. The authors suggest to organize training targeting specific people and produce key advocacy messages emphasizing on the significance of cold chain storage to maintain the quality of oxytocin.…”

“…[19,27,38,42] But due to its heat sensitivity, there have been debates on its cost effectiveness in LMICs. [30,50,52] In these settings, Carbetocin has been found to be as effective as oxytocin without an increase in side effects. [30,31] In settings where oxtytocin is available with existence of cold chain transport and storage available, with health care providers skilled to administer injectable uterotonics, oxtytocin is recommended.…”

Current Resources for Evidence‐Based Practice, January/February 2019

“…A WHO study of drug quality at central storage sites in such countries found that 64% of the oxytocin samples failed testing . A recent qualitative study in 3 lower‐resourced countries about the stability of oxytocin found low knowledge that oxytocin was heat sensitive, as well as difficulties maintaining required storage temperatures because of electricity and refrigeration issues …”