We remember an obstetrician in sub-Saharan Africa, who was asked why he routinely used three vials of oxytocin for a woman after her baby was born. His reply is symptomatic of a world where women still aren’t guaranteed access to quality maternity care including quality medications… “Oh, we always give three to make sure we have the equivalent of at least one dose.”
In many places, getting hold of just one vial of oxytocin to administer to prevent postpartum haemorrhage (PPH) is hard enough. Routine wastage of this sort not only denies other women the chance to receive lifesaving medications, but ends up costing more per patient than slightly more expensive, but quality assured medications. A single dose of a drug that works is cheaper than several doses of poor quality drugs that don’t.
The use of poor quality oxytocin (for example one with less active drug in the ampoule than is stated on the label) may fail to prevent postpartum haemorrhage as intended and result in severe haemorrhage, which can lead to the usage of additional dosages of uterotonics or ultimately the death of the mother. It can also cause healthcare providers to perform procedures that could have been prevented, even including surgical removal of the uterus!
In the case of injectables an additional problem, next to low activity, can be the lack of sterility, which can be the cause of local or general infections, sepsis and also death.
The costs of these additional interventions and those flowing from the death of a mother in childbirth in terms of the health and prosperity of her family can never justify the few cents saved by purchasing cheaper, uncertain quality uterotonics.
The question is, do purchasers really understand the quality problem? Professionals in both the purchasing and donor worlds, as well as healthcare professionals in the field, often think that a product coming from a pharmaceutical manufacturer, from a pharmacy or from a central medical store, is by definition a quality medicine. And therefore they focus more on the price than on anything else. Unfortunately, there is often a real issue with the quality of medicines. Donors, purchasers and healthcare workers must always give equal weight to quality and to price. As stated earlier: the most expensive drug is a drug that does not work, or may even kill!
High quality, low cost uterotonics are available for lower income countries. 1 oxytocin and 3 misoprostol products recently achieved WHO quality assurance in the form of Prequalification and a further 1 achieved temporary ERP approval. Concept Foundation is also collaborating with WHO, MSD for Mothers and Ferring Pharmaceuticals to develop WHO Prequalified Heat-Stable Carbetocin for the prevention of PPH in lower income countries.
Advocacy and communications activities focused on highlighting the importance of quality assurance of medications will contribute to reducing overall healthcare expenditure and improving maternal health outcomes.
Co-Authors: Fiona Theunissen, Project Officer, Access to Maternal Health and Dr Hans Vemer, CEO Concept Foundation.