ALISSA KOSKI & ELLIE MIRZABAGIJHSPH, BALTIMORE, MARYLAND
PATIENCE COFIEPATH, GHANA
RESEARCH SUPPORTED BY THE OXYTOCIN INITIATIVE PROJECT MANAGED BY PATH, WITH FUNDING FROM BILL & MELINDA
GATES FOUNDATION
Perceptions, use and quality of uterotonic substances in Ghana
Presentation Outline
Study objectives and methods
Key findings
Conclusions
Research Objectives
To explore knowledge, perceptions, and usage patterns of uterotonic drugs around birth
And
To assess the chemical potency of a sample of ampoules of oxytocin and ergometrine purchased at private pharmacies, chemical sellers and markets
Methods
In-depth interviews
Simulated client approach
Study Areas
Northern (Savanna belt) Yendi district
Brong Ahafo (Forest belt) Kintampo North district
Western (Coastal belt) Ahanta West district
Sampling and Content for Qualitative Interviews
Sample of Health Care Providers Snowball sampling began at the district health center and
progressed until 10 interviews were conducted (all medical doctors in the district were often included in the sample)
Sample of Community members: A random selection was employed for community
respondentsInterview Topics
Knowledge of and experience with uterotonic substances
Indications for use and dosage
Perceived benefits of using uterotonic substances
Perceived risk of using uterotonic substances
Key Findings from In-Depth Interviews
Place of labor and delivery are influenced by previous and current complication
No evidence of pharmaceutical uterotonic use in communities
No evidence of traditional (herbal) uterotonic use in health facilities
Some midwives give oxytocin to augment prolonged labor at the peripheral/sub-district level
Among midwives, knowledge of risk associated with uterotonics and appropriate dosages is inconsistent
Traditional substances are used during pregnancy and births at home, but TBAs and new mothers are unaware of risks
Labor Augmentation
Some midwives administer oxytocin to augment prolonged labor Doctors are often unavailable or inaccessible to
prescribe a uterotonic Mid-level providers are forced to make a decision
regarding course of treatment independently
“It depends on the midwife who is there she can use her own discretion. Like if you are in the village and there is no doctor, you can’t consult anybody. You have to use your own discretion.” (Midwife, Yendi)
Knowledge of Risk Associated with Use of Uterotonic Drugs during
Labour
Knowledge of risk associated with use of uterotonic drugs during labor is at times incomplete and inconsistent among midwives
“I’m yet to see any negative effect it [oxytocin] has on the patient because it makes work smooth, easy, yes very good.” (Midwife, Ahanta West)
“...during labor if you give the oxytocin it can rupture the uterus so it going to use force and it can affect the baby too so we don’t give during labor .” (Midwife, Kintampo)
Use of Traditional Substances
An enormous variety of traditional substances are used throughout pregnancy and labour Indications for use vary and are at times unclear:
To make the fetus strong To ease delivery To ease stomach pain To ‘make the baby lie down’
Very little consistency in usage patterns for traditional substances Substances used Route of administration Dosage and frequency of use
Variety in Traditional Substances
Kalgutim from Yendi, other substances from Kintampo North and Ahanta West
Simulated Client & Drug Potency Testing
Research Assistants visited 78 randomly selected points of sale across all three districts, including:
Private pharmacy shops Chemical shops Markets Mobile peddlers (Health facility pharmacies)
Statistically, we cannot claim this is a random sample, but it is better than a convenience sample
Total ampoules collected for chemical testing: 101
Small sample – exploratory study
Key Findings from Drug Potency Testing
Active ingredient ranges: Oxytocin: 22.9% - 100.7% Ergometrine: 0% - 120.7%
None (0%) of the ergometrine samples met specifications (active ingredient level between 90-110% of specified level) 55 of 56 ampoules had active ingredient l evel below specified levels (< 90%) One ampoule showed 120.7% active ingredient One ampoule showed 0% active ingredient – suggesting possible counterfeit drug
26% of oxytocin ampoules met specifications (90-110%) 74% of samples did not meet specifications and all showed
active ingredient levels below specification levels (<90%)
Only 4% of oxytocin ampoules were expired, none of the ergometrine ampoules were expired;
The samples of oxytocin and ergometrine that did not meet specifications were purchased from both private pharmacies AND public health facility pharmacies
Interpretation of Drug Testing Results
1. We do not know WHY a majority of drug samples did not meet specifications
We do not know their quality at manufacture OR at departure from manufacturer
We do not know conditions during storage and transportIt is likely that important contributors to low levels of active ingredient are exposure to high temperatures (oxytocin, ergometrine) and/or light (ergometrine)
There was no testing for contamination or Ph
Conclusions and Recommendations
Key Finding: Among midwives, knowledge of risk associated with uterotonics and appropriate dosages associated is inconsistent
Recommendation: Training, supervision and monitoring of midwives should be strengthened, re: AMSTL and PPH treatment
Key Finding: TBAs and new mothers are unaware of risks associated with use of traditional substances during pregnancy and birth
o Recommendation: Behavior change communication program at community level targeting mothers , TBAs and traditional leaders (Queen mothers etc) using both mass media and traditional channels
Conclusions and Recommendations
Key Finding: Majority of available pharmaceutical uterotonics (oxytocin and ergometrine) at the peripheral level are of poor quality Recommendation: Further market surveillance and testing of
uterotonic drug quality is warranted
Investigation and improvements to the transportation, distribution and storage of uterotonic drugs
Enforcement of regulations on sale of uterotonic drugs (oxytocin and ergometrine) by the Ghana Pharmacy Council
Catherine Carr – [email protected]
Thank you for your Attention and
Support!
