Preventing Postpartum Hemorrhage with Oxytocin in the Uniject Injection System

This article on postpartum haemorrhage (PPH) prevention and treatment presents the author, Dr. Shirley Villadiego's discussion of programmatic experience in Central America with oxytocin provided in the form of the Uniject™ injection system (oxytocin in Uniject - OIU), presented to the Maternal and Child Integrated Health Program (MCHIP) in February of 2013. "In an effort to increase coverage and extend use of oxytocin to remote areas, MCHIP, PATH, ministries of health, nongovernmental organizations, and partners from the private sector have worked together to conduct pilot projects to demonstrate proper use, acceptability, and feasibility of using oxytocin in the Uniject™ injection system to prevent PPH in rural areas in Guatemala, Honduras and Nicaragua."

Because the World Health Organization (WHO) recommends that oxytocin be administered by a skilled provider within one minute of delivery of the baby as part of active management of the third stage of labour (AMSTL), the OIU, a pre-filled, single-dose, non-reusable injection technology, was developed. Some of the goals were:

1. Administration by skilled birth attendants (SBAs), auxiliary nurses, or other trained lay providers.
2. Use in areas of limited health facility infrastructure and/or health worker shortages.
3. Progress toward overcoming acceptability concerns, including fear of injections, and safety concerns, regarding reuse of needles.

Reported results include:

• In 2009, a pilot study in Guatemala assessed the acceptability of OIU by SBAs and managers and found that providers reported easy use, but there were some issues related to stock outs and cold chain problems.
• In Honduras in 2010, OUI was evaluated as easy to use by 93% of those surveyed, including the following benefits reported by providers: increased confidence in effectiveness of the medication due to a time temperature indicator (TTI) on the packaging; reduced wastage of the medication; and increased awareness of the importance of AMSTL.
• "In Nicaragua, an operational study was conducted with SBAs to assess whether a multifaceted intervention increased use of prophylactic oxytocin during the third stage of labor and reduced the number of routine episiotomies. The intervention included the development and dissemination of guides, clinical training of providers, use of reminders, and the introduction of OIU for PPH prevention during AMTSL. Rates of oxytocin were already quite high in Nicaragua prior to the intervention. However, there was still a statistically significant increase in its use after the intervention (95% to 98%). In addition, high levels of delayed cord clamping and controlled cord traction increased and uterine massage remained stable. The episiotomy rate decreased from 31% to 20% and routine episiotomies for primiparous women decreased from 59.6% to 40.1%. In all, 83% of providers reported that OIU simplified the administration of oxytocin during AMSTL. "

Challenges and opportunities are described as:

• Ease of use offers the opportunity to train a wider range of providers, increasing AMSTL in births in remote locations.
• The global environment for rolling out OIU is timely due to the United Nations Commission on Life-saving Commodities for Women's inclusion of oxytocin and possible interest by other organisations in supporting market development efforts for OIU.
• Challenges include cost, cold chain requirements, and restrictions due to "a lack of current policies in place that allow lower SBAs to use injectable medications during the third stage of labor."