Imagine a scenario where a woman prepares for her upcoming birth with her family. She organizes the necessary transportation to travel a long distance, and saves enough money to pay for the delivery. She’s done everything possible to ensure her birth will take place in a facility with a skilled provider.
Following delivery of her baby, the woman begins to hemorrhage. The nurse-midwife administers oxytocin—a drug designed to stop the bleeding—but she continues to hemorrhage. After losing too much blood, the woman dies.
The problem? The drug that could have saved this woman’s life was no longer potent enough because it was exposed to too much heat. Despite doing everything she could to give birth safely, the last piece of the puzzle to managing an obstetric complication—an effective drug—failed her.
This scenario is all-too-common in the developing world. Every seven minutes a woman dies from postpartum hemorrhage, even though we already know how to prevent these deaths. All women need access to oxytocin (the preferred first line drug), or misoprostol during the third stage of labor. Projections show that if oxytocin and misoprostol were available to all women giving birth, 41 million postpartum hemorrhage cases could be prevented and 1.4 million lives could be saved over a 10-year period.
However, the implication in these projections is that women would be accessing high-quality, effective drugs. One of the most serious challenges related to oxytocin is the speed with which it degrades at high temperatures.
Chad had a maternal mortality rate of 1100 maternal deaths per 100,000 live births in 2010 (around 300 maternal deaths per 100,000 live births is considered “high maternal mortality”). As I am writing this blog, it is currently 97⁰F at 8 p.m. in Chad. At such high temperatures, oxytocin can retain its necessary potency for only about one week.
The World Health Organization recommends that oxytocin be refrigerated “as much as possible” during storage and distribution. But this is not a requirement and many lower-level health facilities lack a refrigerator to ensure that oxytocin is consistently kept cool. The United Nations Commission on Life-Saving Commodities for Women and Children has called for placing oxytocin in the cold chain used for the Expanded Program on Immunization. A cold chain refers to the storage and transport equipment that enable medicines to be kept between 36-45⁰F from the point of manufacture to the point of use.
Formally integrating oxytocin into the cold chain is a crucial step toward ensuring that women receive effective drugs during delivery. However, this would also require working with manufacturers to change their packaging. On a recent trip to Malawi, the pharmacy manager for the Christian Health Association of Malawi informed me he didn’t know about oxytocin’s potential to degrade due to high temperatures. The boxes only said to store the drug in a cool, dry place. In countries like Chad there literally is not a cool place for half year—unless you use a refrigerator. Pharmacy managers, medical store staff, and health facility managers need to be aware of the fact that oxytocin really should be refrigerated. Packaging is one clear and irrefutable way to convey that information.
#MomsMatter is a mini blog series running through Mother’s Day. We’ll be talking about the critical need for maternal health supplies. Read the first post here. And stay tuned for more all this week!