By PPH Foundation
The difference between life and death after childbirth can sometimes depend on something as simple as a working refrigerator.
Across many low-resource settings, healthcare workers depend on oxytocin to prevent postpartum haemorrhage, one of the most dangerous complications of childbirth. For decades, oxytocin has been the gold-standard medicine used immediately after birth to help the uterus contract and prevent excessive bleeding. Yet there is a challenge that rarely makes headlines: oxytocin is highly sensitive to heat.
From national warehouses to county hospitals, from health centres to remote dispensaries, oxytocin must be stored and transported at temperatures between 2°C and 8°C. Maintaining this "cold chain" requires reliable refrigeration, electricity, temperature monitoring systems, and uninterrupted transport networks. In many rural and hard-to-reach communities, these conditions cannot always be guaranteed.
As a result, medicines that leave central stores in good condition may arrive at health facilities with reduced potency, potentially compromising their effectiveness when mothers need them most.
Research has repeatedly documented the challenge. A systematic review by Torloni and colleagues published in PLOS ONE in 2020 found widespread concerns regarding oxytocin quality and storage conditions in low- and middle-income countries. The authors reported that exposure to heat during storage and transportation can accelerate degradation, raising concerns about the medicine's ability to perform optimally in settings where cold-chain systems are weak (Torloni et al., 2020).
Recognising this challenge, researchers began searching for an alternative uterotonic that could withstand higher temperatures without losing effectiveness. Their efforts led to the development of heat-stable carbetocin.
Unlike oxytocin, heat-stable carbetocin remains stable for extended periods at temperatures up to 30°C and does not require refrigeration. This characteristic has attracted significant global attention because it addresses one of the most persistent logistical barriers to preventing postpartum haemorrhage in tropical and resource-constrained environments.
The breakthrough was supported by a landmark multicountry trial involving nearly 30,000 women across ten countries. Published in The New England Journal of Medicine in 2018, the study found that heat-stable carbetocin was non-inferior to oxytocin in preventing postpartum haemorrhage after vaginal birth (Widmer et al., 2018). In practical terms, this meant that women receiving heat-stable carbetocin experienced similar protection against severe bleeding as those receiving refrigerated oxytocin.
The findings were significant enough to influence global policy discussions. In 2019, the World Health Organization updated its recommendations, stating that heat-stable carbetocin may be used for the prevention of postpartum haemorrhage in settings where its cost is comparable to other effective uterotonics and where cold-chain storage of oxytocin cannot be reliably guaranteed.
For healthcare workers serving remote communities, this represents more than a pharmaceutical advancement. It is a solution to a longstanding operational challenge.
Imagine a health facility in a remote area where power outages are frequent, vaccine refrigerators are overburdened, and transportation delays are common. Maintaining ideal storage temperatures around the clock may be difficult despite the best efforts of healthcare teams. A medicine that remains effective without refrigeration can provide greater confidence that women are receiving a quality-assured uterotonic at the point of care.
According to Prof Moses Obimbo, Project Lead of the End PPH Initiative and a Professor at the University of Nairobi, innovations that address health system barriers are essential in the fight against maternal mortality.
"Preventing postpartum haemorrhage is not only about having effective medicines. It is also about ensuring those medicines reach women in a condition that allows them to work as intended. Heat-stable carbetocin offers an important opportunity for settings where maintaining a reliable cold chain remains challenging. By reducing dependence on refrigeration, it helps bring effective prevention closer to women wherever they give birth."
Despite its promise, experts emphasise that heat-stable carbetocin is not intended to replace oxytocin everywhere. Oxytocin remains highly effective when quality-assured products are stored correctly and administered appropriately. Instead, heat-stable carbetocin expands the options available to health systems, particularly in regions where environmental and infrastructure challenges threaten medicine quality.
The conversation therefore extends beyond a comparison of two drugs. It highlights a broader reality in maternal health: innovations that simplify delivery systems can be just as important as innovations that improve clinical performance.
As countries work toward reducing preventable maternal deaths, ensuring access to effective uterotonics remains a priority. In places where refrigeration cannot always be guaranteed, heat-stable carbetocin may offer a practical and potentially lifesaving solution. Sometimes, the battle against postpartum haemorrhage is fought not only in the delivery room, but also along the supply chain.
Sources
- Widmer M, Piaggio G, Nguyen TMH, et al. Heat-Stable Carbetocin versus Oxytocin to Prevent Hemorrhage after Vaginal Birth. New England Journal of Medicine. 2018;379(8):743-752.
- World Health Organization. WHO Recommendations: Uterotonics for the Prevention of Postpartum Haemorrhage. Geneva: WHO; 2019.
- Torloni MR, Gomes Freitas C, Kartoglu UH, Metin Gülmezoglu A, Widmer M. Quality of Oxytocin Available in Low- and Middle-Income Countries: A Systematic Review of the Literature. PLOS ONE. 2020;15(10).
- Gallos ID, Williams EV, Devall AJ, et al. Advancing Postpartum Haemorrhage Prevention and Management Through Health System Innovations. The Lancet Global Health. 2024.
- International Federation of Gynecology and Obstetrics. FIGO Recommendations on the Prevention of Postpartum Haemorrhage. London: FIGO.
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