Clinical experiences with the use of oxytocin injection by healthcare providers in a southwestern state of Nigeria: A cross-sectional study

Background
Postpartum hemorrhage (PPH) is a leading cause of maternal mortality in Nigeria and in most low- and middle-income countries. The World Health Organization (WHO) strongly recommends oxytocin as effective, affordable, and the safest drug of first choice in the prevention and treatment of PPH in the third stage of labor. However, there are concerns about its quality. Very high prevalence of poor-quality oxytocin, especially in Africa and Asia, has been reported in literature. Excessive and inappropriate use of oxytocin is also common in low-resource settings.
Objective
To assess clinical experiences with quality of oxytocin used by healthcare providers in Lagos State, Nigeria.
Methods
This was a descriptive cross-sectional study conducted in 2017, with 705 respondents (doctors and nurses) who use oxytocin for obstetrics and gynecological services recruited from 195 health facilities (public and registered private) across Lagos State. Data collection was quantitative, using a pretested self-administered questionnaire. Data analysis was performed with IBM SPSS version 21. Statistical significance was set at 5 percent (p<0.05). Ethical approval was obtained from Lagos University Teaching Hospital Health Research Ethics Committee.
Results
Only 52 percent of the respondents knew oxytocin should be stored at 2°C to 8°C. About 80 percent of respondents used oxytocin for augmentation of labor, 68 percent for induction of labor, 51 percent for stimulation of labor, and 78 percent for management of PPH. Forty-one percent used 20IU and as much as 10% used 30IU to 60IU for management of PPH. About 13 percent of respondents reported believing they had used an ineffective brand of oxytocin in their practice. Just over a third (36%) had an available means of documenting or reporting perceived ineffectiveness of drugs in their facility; of these, only about 12 percent had pharmacovigilance forms in their facilities to report the ineffectiveness.
Conclusion
The inappropriate and inconsistent use of oxytocin, especially overdosing, likely led to the high perception of medicine effectiveness among respondents. This is coupled with lack of suspicion of medicine ineffectiveness by clinicians as a possible root cause of poor treatment response or disease progression. Poor knowledge of oxytocin storage and consequent poor storage practices could have contributed to the ineffectiveness reported by some respondents. It is necessary to establish a unified protocol for oxytocin use that is strictly complied with. Continuous training of healthcare providers in medicine safety monitoring is advocated.

背景
产后出血（Postpartum hemorrhage，PPH）是尼日利亚以及大多数中低收入国家孕产妇死亡的首要诱因。世界卫生组织（World Health Organization，WHO）强力推荐催产素（oxytocin）作为产程第三阶段预防和治疗产后出血的有效、可负担且最安全的首选药物。然而，其质量问题引发了诸多担忧。现有文献报道，不合格催产素的检出率极高，尤其在非洲与亚洲地区。在资源匮乏的医疗环境中，催产素的过度与不当使用也屡见不鲜。

研究目的
本研究旨在评估尼日利亚拉各斯州医疗服务提供者使用的催产素的质量相关临床实践经验。

研究方法
本研究为2017年开展的描述性横断面研究，从拉各斯州全境195家医疗机构（公立及注册私立机构）中招募了705名从事妇产科诊疗、使用催产素的医护人员（医生与护士）作为研究对象。数据收集采用定量方法，使用经过预试验的自填式问卷进行。数据分析采用IBM SPSS 21.0版本完成，设定统计学显著性阈值为5%（p<0.05）。本研究已获得拉各斯大学教学医院健康研究伦理委员会的伦理审查批准。

研究结果
仅有52%的研究对象知晓催产素需储存于2℃至8℃的环境中。约80%的研究对象使用催产素进行产程加强，68%用于引产，51%用于产程刺激，78%用于产后出血的处置。41%的研究对象在产后出血处置中使用20IU剂量，且多达10%的研究对象使用30IU至60IU的高剂量。约13%的研究对象称，在临床工作中曾使用过无效批次的催产素。仅有略超三分之一（36%）的医疗机构具备记录或上报所感知到的药物无效性的渠道；在这些具备渠道的机构中，仅约12%配备了药物警戒（pharmacovigilance）报表以上报药物无效情况。

研究结论
催产素的不当与不规范使用，尤其是过量给药，可能导致研究对象对药物有效性的认知偏高。加之临床医师未对药物无效性产生怀疑，这可能是治疗应答不佳或病情进展的根本诱因。对催产素储存知识的匮乏以及由此导致的不当储存行为，可能也是部分研究对象报告药物无效的原因之一。亟需制定统一的催产素使用规范并严格执行。同时应持续开展针对医护人员的药物安全监测培训。