Nigeria: Scaling Heat-Stable Uterotonics to Prevent Maternal Deaths in Nigeria

Every day, countless mothers around the world lose their lives to postpartum haemorrhage (PPH), a devastating reality that remains a widespread and persistent challenge in Nigeria. The country accounts for 28.5% of global maternal deaths, with PPH being a major contributor, causing 22% of these tragic losses.

A webinar hosted by Smiles for Mothers in collaboration with Nigeria’s Ministry of Health and Social Welfare and Ferring Pharmaceuticals, brought leading experts together to discuss the “Best Practice on the Use of Heat-Stable Carbetocin (HSC) and Other Uterotonics for Prevention of Postpartum Haemorrhage (PPH) in Nigeria“.

As healthcare systems in low-resource settings continue to struggle with inconsistent cold chain infrastructure, HSC offers a breakthrough solution by maintaining its potency at higher temperatures, improving access to effective PPH management solutions.

Other Uterotonics and how they faired

Oxytocin is the current gold standard and first-line agent in the prevention and treatment of PPH due to its efficacy and rapid onset of action. However, one of the biggest barriers of using oxytocin to effectively manage PPH in Nigeria is its dependence on a functional cold chain system from the point of manufacture to the point of use.

This life-saving, however requires refrigeration at 2°C to 8°C to maintain its effectiveness. Yet, many rural clinics and primary healthcare centres (PHCs) struggle with consistent power supply. Up to 40% of PHCs in Nigeria lack access to electricity, making cold storage unreliable. As a result, oxytocin often loses its potency before it can be administered, rendering it ineffective in preventing excessive bleeding after childbirth.

Naanma Kangkum, Manager at Solina Centre for International Development and Research (SCIDaR) noted during the webinar that findings from a national audit of uterotonics in Nigeria revealed that 74% of oxytocin samples failed potency tests due to improper storage and substandard production. The audit also revealed that 34% of misoprostol samples, another common uterotonic, failed to meet required efficacy standards. Highlighting the economic impact, Kangkum noted that poor-quality uterotonics cost Nigeria an estimated $73 million annually due to treatment failures and increased healthcare expenses.

Unlike oxytocin which requires refrigeration, HSC eliminates the cold chain challenge as it remains stable at temperatures up to 30°C. This makes it far more practical in low-resource settings where maintaining a consistent cold chain is difficult.

According to Dr. Vishal Shah, Director at Ferring Pharmaceuticals who spoke during the webinar, “Heat-Stable Carbetocin represents a critical shift in how we approach PPH prevention. It reduces the burden on healthcare providers while ensuring consistent effectiveness in resource-limited settings.”

The efficacy of HSC: The CHAMPION Trial

The CHAMPION trial, one of the largest studies on uterotonics, confirmed that HSC is as effective as oxytocin in preventing PPH. The trial was conducted across 10 countries with over 29,000 women and demonstrated that HSC led to comparable reductions in blood loss while offering the added benefit of temperature stability. The CHAMPION trial found that HSC can last 4 to 10 times longer than oxytocin, enabling prolonged uterine contraction with a single 100 micro grams injection, administered intravenously or intramuscularly, and reducing the need for multiple doses. Using HSC for PPH prevention was also found to be more cost-effective compared to other uterotonics (oxytocin, misoprostol), meaning that over time, using it can significantly reduce healthcare spending related to treating PPH complications.

Speaking further, Naanma highlighted that the Smiles for Mothers programme has collaborated with various stakeholders since 2020 to support the roll out and adoption of WHO recommendations of uterotonics for PPH prevention, specifically HSC, through three (3) journeys:

1. Policy Adoption Journey: States and the National Government were supported in developing a costed roadmap for adopting the 2018 WHO recommendations on the use of uterotonics for the prevention of postpartum haemorrhage, particularly advocating for heat-stable formulations in low-resource settings. This process also facilitated policy reviews, updates to the Essential Medicines List, revisions to training manuals, and securing a regulatory approval from NAFDAC for the importation and use of HSC in Nigeria.

2. Product Journey: Collaboration with states such as Kano, Lagos and Niger to integrate HSC procurement planning into their operational plans. Provided support for healthcare worker training and assisted states in seeding HSC into their Drug Revolving Fund (DRF), leading to sustained procurement over time.

3. Patient Journey: Conducted implementation research to assess health worker acceptability of HSC, while also building the capacity of health workers in active management of the third stage of labour (AMTSL). Additionally, provided patient literacy materials to women in communities to generate demand for health services within local health facilities.

Speaking during the webinar, Dr. Chukwunonso Nwaokorie, Principal at Solina Centre for International Development and Research, highlighted that a public-access priced version of HSC Carbetocin is now available in the Nigerian market. This was made possible through a partnership between MSD for Mothers, Ferring Pharmaceuticals, and the World Health Organisation (WHO).

Scaling the Use of HSC through the MAMII Strategy

At the Joint Annual Review (JAR) meeting that held in November 2024, the Coordinating Minister of Health and Social Welfare, Professor Muhammad Ali Pate, launched the Maternal Mortality Reduction Innovation Initiative (MAMII) with the aim to reduce maternal mortality in Nigeria by increasing facility utilisation, promoting deliveries by skilled birth attendants and reducing maternal and neonatal mortality by 30% in 172 priority Local Government Areas (LGAs). These LGAs, spread across 33 states, accounts for over 50% of maternal deaths in Nigeria.

Key supply side interventions of the MAMII strategy include training 120,000 frontline healthcare workers; improving PHC functionality and expanding Basic Healthcare Provision Fund (BHCPF) primary healthcare centres (PHCs) to 17,600; deployment of Maternal and Neonatal Health (MNH) innovations and ensuring the availability of responsive emergency management and referral systems, and sustainable health financing. Deploying and scaling of HSC as a key MNH innovation can be achieved through the following recommended actions:

· Strengthening procurement and supply chain systems: The Federal Government of Nigeria should allocate funds to scale up the procurement and distribution of HSC across all states. To ensure consistent availability, procurement guidelines should also be developed at the national and state levels with a focus on preventing stockouts and promoting equitable distribution, especially in LGAs where the burden of maternal mortality is highest.

· Expanding PHC facility capacity: A core objective of MAMII is the expansion of BHCPF to 17,600 functional PHC facilities nationwide. These PHCs should be adequately equipped with essential maternal health commodities, including supplies for prevention, identification and treatment of PPH like heat stable uterotonics and calibrated drapes, and other components of the E-MOTIVE treatment bundle.

· Training and capacity building for healthcare providers: The MAMII strategy aims to train 120,000 frontline healthcare workers to improve maternal health service delivery. Professional associations such as Society of Gynaecology and Obstetrics of Nigeria (SOGON) and National Association of Nigerian Nurses and Midwives (NANNIM) should facilitate workshops and trainings to upskill health workers on the best practices and the effective use of HSC for the prevention of PPH. These training courses should be incorporated into pre-service and in-service curriculum of healthcare workers.

· Ensuring sustainable financing for HSC Procurement: The MAMII strategy seeks to integrate innovative financing mechanisms to support maternal health interventions. To guarantee sustainable supply, the federal government should incorporate HSC procurement into the Basic Healthcare Provision Fund (BHCPF) allocations and ensure that HSC is covered under maternal health insurance benefits.

Preventing PPH is critical to improving maternal health outcomes and HSC offers a promising solution due to its efficacy and suitability for low-resource settings. By adopting best practices in its utilisation and aligning it with the Federal Government’s MAMII strategy, stakeholders can work together to significantly reduce the burden of PPH and save the lives of countless mothers in Nigeria.