By Chukwunonso Nwaokorie

The implications go far beyond a delivery ward. When a mother dies, the effects ripple through families and communities. Newborns face greater risks, households lose caregivers and income earners, and children are often forced to navigate life without the person most central to their wellbeing. Reducing maternal mortality is not only a health priority. It is a social and economic imperative.

The cheapest vial is not the cheapest choice
I know what a manager or procurement officer sees when these two products sit side by side on a budget line. Heat-stable carbetocin (100mcg) costs about 2000 naira a vial. Oxytocin (10IU) costs 800 naira. On paper, the decision looks obvious, and the wrong one appears prudent. But that is only because the budget line does not show you the full bill.

When we added up the real cost of care per patient, heat-stable carbetocin came out the lowest of the uterotonics we studied, at about N3,838.74, compared with N6,042.8 for oxytocin driven by multiple dosing and need for blood transfusion. The reason is simple: Too often, procurement decisions are driven by unit price rather than total cost of care.

That approach may save money at the point of purchase, but it can cost far more when complications, repeat dosing, emergency referrals, and blood transfusions become necessary.

Scaled across the country, the savings are real, roughly 960 million naira a year if we reach a quarter of deliveries, and 2.30 billion at half. Choosing the cheaper vial does not save money. It moves the cost to the emergency ward, to the blood bank, and to the family that buries a mother.

A word to our policymakers and health managers
There is a group whose decisions shape maternal health as much as any clinician’s, those are the policy makers and health managers. The evidence clearly shows that procurement and financing priorities should be guided by value, not unit price alone. Although HSC has a higher unit acquisition cost than oxytocin, its association with lower incidence of PPH, blood transfusion, maternal complications, and stillbirth, results in the lowest overall cost of care per woman.

HSC does not require refrigeration, making it particularly well suited to Nigeria’s health system, where maintaining a reliable cold chain remains a challenge. National illustrations suggest that scaling HSC use to 75 per cent could potentially generate about N3.7 billion in annual savings from only direct costs while improving maternal outcomes.

The implication is straightforward: prioritising HSC in maternal health procurement and financing plans, supporting its phased scale-up, and strengthening its availability and use is a profitable investment in healthier mothers and children that will ultimately result in more efficient use of health resources, and a stronger health system in Nigeria.

The gap is no longer evidence. it is action
If the evidence is settled, the policy foundation is in place, and the providers who have used the medicine trust it, why is it still on so few shelves? In my view, the answer is not clinical resistance. It is procurement and financing. A medicine does not reach a labour ward because it is not included in a guideline. It reaches the ward because a state or a facility budgets for it, buys it, and keeps it in stock. Oxytocin remains the default simply because it is already built into how we purchase.

We have shown this can change. HSC has been introduced through Drug Revolving Fund mechanisms in states like Kano, Lagos, and Niger, and where it has been introduced, it has been used. The task now is to make that the norm rather than the exception. I would respectfully suggest that the single most useful step is for our procurement systems, at the national and state levels, to treat HSC as a priority for routine prevention of postpartum haemorrhage. Availability follows procurement, and use follows availability.

Updating facility formularies to align with the 2022 guidelines and bringing the medicine into clinical training. But it begins with the decision to buy it.

is not alone in this transition. Other LMICs such as Kenya have demonstrated what moving from policy to practice looks like by complementing guideline updates with robust financing and procurement mechanisms that have expanded access across multiple counties. Uganda has similarly begun translating policy into practice through the phased introduction of heat-stable carbetocin into public-sector maternity services. These examples demonstrate that improving access requires more than updating clinical guidelines – it requires aligning policy with procurement, financing, and implementation to ensure the medicine reaches the women who need it the most.

Nigeria decided a few years ago that heat-stable carbetocin belongs in our health system, and recent evidence shows it is particularly well suited to our health system but only about 1 in every 13 women delivering get the medication, suggesting that the policy changes have yet to translate into widespread adoption. The next step is to prioritise HSC for routine PPH prevention in Nigeria by strengthening policy and aligning it with procurement, and financing priorities and we now have real-world evidence to that. The big question is no longer whether HSC works, but whether our policies and financing mechanisms and priorities will ensure it is routinely available to every woman who needs it.

Concluded.

Dr Nwaokorie is a Principal at the Solina Centre for International Development and Research (SCIDaR), where he oversees a portfolio of health programmes including Smiles for Mothers, which conducted the multistate study referenced here. The full study will be released as part of SCIDaR’s dissemination of its findings on uterotonic effectiveness in Nigeria.