Integrating Heat-Stable Carbetocin into Routine Maternal Care: Lessons from District-wide Implementation of an AMTSL Strengthening Model in India

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.