Perceptions, use and quality of
uterotonic substances in Ghana
ALISSA KOSKI & ELLIE MIRZABAGI
JHSPH, BALTIMORE, MARYLAND
PATIENCE COFIE
PATH, GHANA
RESEARCH SUPPORTED BY THE OXYTOCIN INITIATIVE
PROJECT MANAGED BY PATH, WITH FUNDING FROM
BILL & MELINDA GATES FOUNDATION
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 respondents
 Interview 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
“...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)
“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)
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
We do not know WHY a majority of drug samples
did not meet specifications
1.

We do not know their quality at manufacture OR at
departure from manufacturer

We do not know conditions during storage and transport


It 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 – ccarr@jhpiego.net
Thank you for your
Attention and Support!