By  Chukwunonso Nwaokorie

We are no longer asking whether heat-stable carbetocin works. We have the global evidence, the national policy, and now Nigerian data of our own. The question that remains is far more uncomfortable: why are so many women still not receiving it?

I have spent years working on this problem, first in healthcare delivery and now in the development sector, and I want to be honest about how it feels to sit where I sit today. Nigeria continues to carry one of the world’s highest burdens of maternal mortality, with thousands of women dying every year from causes related to pregnancy and childbirth. We know how to stop most women from bleeding to death after childbirth. And yet postpartum haemorrhage remains one of the leading causes of maternal death in Nigeria. This is both the encouraging part and the frustrating part of this work: the answer exists, and mothers are still dying for want of it.

Let me give you a sense of what that looks like away from the statistics. While visiting a PHC in Northern Nigeria, we once sat with a matron, I will call her matron Z in this piece, who has given most of her life to a facility that opened in 1996. She took us back to a night early in her career. It was dark and quiet on the ward when a mother in her mid-thirties, already with eight children, came in to deliver her ninth. The delivery was smooth, oxytocin was administered for PPH prevention and her vitals were normal. “She delivered safely,” the matron recalled. “She was even smiling, asking her husband to bring tea.”

Around half past nine, the bleeding began. The team gave the uterotonics they had and set up an oxytocin drip, but it would not stop. There was no ambulance driver that night, no blood to transfuse. The police station sat just across the road, its lights visible from the ward, and the staff ran over to beg for help moving her. It did not come in time. As the hours passed toward midnight, the woman grew weaker and thirstier, until she asked Asabe to call her husband and tell him to forgive her. “That is why, even now, when I tell the story, I cry. Because she was not sick, she should have lived. We had nothing else to help her then. But sometimes I wonder, what if we had the Heat Stable Carbetocin we have now, perhaps she might be alive now.” – Matron Z.

This is why I am writing: that same facility has not lost a mother to postpartum haemorrhage in over a year, because today it has better protocols, and commodities like heat-stable carbetocin on the shelf. What stays with me about matron Z’s story is not just the tragedy but the preventability.

Why the drug we rely on keeps failing us
The medicine most Nigerian facilities use for preventing postpartum bleeding is oxytocin. It works, but only if it is kept cold, between two and eight degrees, every step of the way from the factory to the mother. Now imagine how possible it is to maintain this temperature range from the port to the trucks to the stores and eventually to the labour ward. In a country where power supply is rarely guaranteed, that is a promise we cannot keep. I have walked into facilities and found oxytocin sitting in a cupboard or on an open shelf, not because anyone was careless, but because the refrigerator does not hold and the power does not stay on.

An ineffective vial of oxytocin looks exactly like a good one. So when a dose doesn’t work and bleeding continues, providers do the rational thing: they give more. In ours and several other studies, almost half of the women who received oxytocin were given above-standard doses, some four times the recommended amount. I cannot blame a single one of those providers. When a woman is bleeding in front of you, you reach for what you have and use more of it because you do not trust that it will work. The instinct is sound, the result is catastrophic. The system that creates it is broken.

So we generated the evidence ourselves
For a long time, the case for heat-stable carbetocin in Nigeria rested on trials conducted elsewhere, under conditions that bear little resemblance to a busy labour ward in Kano or Rivers. I did not think that was good enough. If we were going to ask Nigerian policymakers, procurement officers, and clinicians to change what they do, we owed them evidence from Nigeria. So through SCIDaR’s Smiles for Mothers programme, we ran one of the largest studies of its kind in this country and one of the first in the world: outcomes across 373 facilities, in seven states, spanning all six geopolitical zones, covering tens of thousands of deliveries under ordinary clinical conditions – real-world conditions. I encourage anyone with a stake in maternal health, in government, in pharmaceuticals, in our professional bodies, to read the full study when it is released.

Here is what we found. Postpartum haemorrhage occurred in 4.4 per cent of the women who received heat-stable carbetocin, against 10.2 per cent of those who received oxytocin. When we analysed the results, I was not surprised. For years, clinicians and frontline health workers like matron Z have described the challenges they faced with oxytocin in real-world settings. What the study provided was something equally important: Nigerian evidence, generated under Nigerian conditions, that confirmed what many providers already suspected.

After adjusting for the clinical and social factors we could measure, the odds of haemorrhage with oxytocin were more than twice as high. Heat-stable carbetocin needs no refrigeration, holds its potency at up to thirty degrees for three years, and works in a single standard dose. Put plainly: a woman given this medicine is far less likely to bleed dangerously after childbirth. For her and her family, that is the difference between going home and not, between a child and an orphan or between a husband and a widower.

To be continued tomorrow.

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