Integrating Heat-Stable Carbetocin into Routine Maternal Care: Lessons from District-wide Implementation of an AMTSL Strengthening Model in India
The integration of heat-stable carbetocin into routine maternal care achieved high coverage and timely administration, with a lower incidence of postpartum hemorrhage compared to oxytocin in this observational study.
Where it sits
this study against the rest of the oxytocin corpusSummary and findings
This study evaluated the integration of heat-stable carbetocin (HSC) into maternal care to address postpartum hemorrhage (PPH) in India. A total of 48,487 institutional deliveries were recorded, with 99.9% receiving prophylactic uterotonics. Among those receiving HSC, 200 (0.48%) developed PPH, compared to 75 (1.10%) among those receiving oxytocin.
Abstract
Postpartum haemorrhage (PPH) remains the leading direct cause of maternal mortality globally, with a disproportionate burden in low- and middle-income countries. Although prophylactic uterotonics are effective, their impact is often constrained by health system limitations, including unreliable cold-chain storage affecting oxytocin quality. Heat-stable carbetocin (HSC) offers a thermally stable alternative; however, evidence on its large-scale integration into routine public health systems remains limited. We conducted a district-wide implementation evaluation of an HSC-based Active Management of the Third Stage of Labour (AMTSL) strengthening model across 32 public-sector delivery facilities in Dewas district, Madhya Pradesh, India. Implemented through a phased public–private partnership, the model integrated HSC into routine labour room practice alongside provider capacity building, strengthened documentation, and supportive supervision. A retrospective observational design was used to analyse routinely collected facility-level data from August 2022 to December 2024. Key outcomes included prophylactic uterotonic coverage, timeliness of administration, PPH incidence, and management practices. A total of 48,487 institutional deliveries were recorded during the study period. Documented prophylactic uterotonic coverage was nearly universal (99.9%), with administration within one minute of birth achieved in 99.4% of deliveries. Among deliveries with documented prophylactic uterotonic use, 41,658 (85.9%) received HSC and 6,812 (14.1%) received oxytocin. Overall, 275 PPH cases (0.57%) were documented. Among women receiving HSC prophylaxis, 200 (0.48%) developed PPH, compared with 75 (1.10%) among those receiving oxytocin. These findings are descriptive because prophylactic uterotonic allocation reflected routine programme implementation rather than random assignment. Uterine atony was the leading documented cause of PPH (176/275; 64.0%). Management included tranexamic acid in 239 (86.9%) cases, intravenous fluids in 273 (99.3%), blood transfusion in 36 (13.1%), and referral to a higher-level facility in 84 (30.5%) cases. HSC uptake was significantly higher in First Referral Units than non-FRU facilities (89.3% vs. 81.4%; p<0.001), as was administration within one minute among HSC recipients (100% vs. 98.7%; p<0.001). District-wide implementation of an HSC-based AMTSL strengthening model achieved high coverage and timely administration of prophylactic uterotonics across public-sector facilities operating at different levels of obstetric capacity. The findings provide real-world implementation evidence supporting the feasibility of integrating HSC into routine government maternity services using existing health-system infrastructure, supervision, and reporting mechanisms. Such embedded implementation approaches may offer a pragmatic pathway for strengthening PPH prevention in settings where reliable maintenance of the oxytocin cold chain remains challenging.
Background
Not reported in abstract.
Methods
Not reported in abstract.
Results
Not reported in abstract.
Interpretation
Not reported in abstract.
Limitations
Not reported in abstract.