Antenatal Corticosteroids for Threatened Preterm Delivery

Prof. Elwyn Chomba, MBChB, DCH, MRCP Permanent Secretary Ministry of Community Health, Mother and Child Health,ZM Global Network for Womens and Childrens Health Research

Background
Global health perspective
Preterm birth (PTB) is the second leading cause of Under-5 mortality, after pneumonia 1.1 million children die from direct complications of preterm birth

Background
Key evidence-based interventions during pregnancy and childbirth?
Understand the gestational clock triggering the onset of labour Identify the causal pathways leading to preterm labour and delivery

Background
However, until there is better understanding of the onset of labor and the causal pathways, improved management of preterm birth can reduce mortality and major morbidities

Key Evidence-Based Interventions for Threatened Preterm Delivery

Antenatal corticosteroids to reduce mortality and major morbidities (i.e., RDS) from prematurity Antibiotics for premature rupture of membranes (pPROM) to prevent severe morbidity

Roberts & Dalziel, 2006; Kenyon et al, 2010; Doyle LW et al, 2010; Lawn et al, 2010

Benefits of Antenatal Corticosteroids

Antenatal corticosteroid administration is the most effective intervention during pregnancy to reduce neonatal mortality from preterm birth
ACS also reduce respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), sepsis, necrotizing enterocolitis, and neurodevelopmental impairment
Roberts & Dalziel, 2006

Despite their effectiveness, antenatal corticosteroid use in lowand middle-income countries

Antenatal Corticosteroids Use During Preterm Labour

100%

80%

30%
4% - 71%

10%

5%
LMIC
N=42

HIC

LMIC

N=75 Jones et al 2003 Darmstadt et al 2005 Born Too Soon report 2012

Latin America
N=6

Why is such an effective, safe, easy to administer, and inexpensive intervention is still underused in lowand middle-income countries?

Factors Related to the Underuse (1)

Pending questions
Is the effect similar at community level than at hospital level? Are they beneficial at the recommended/relevant gestational ages?

Factors related to organization

Lack of availability of the drug Difficulty in timely identification and treatment

Factors Related to the Underuse (2)

Factors related to health providers and policy makers Lack of awareness and familiarity with ACS Competence to determine GA Local regulations about who can administer the medication Factors related to women Lack of access to an appropriate level of care Lack of knowledge and awareness

Antenatal Corticosteroids Trial in Preterm Births to Increase Neonatal Survival in Developing Countries (ACT Trial)

To evaluate whether a community-level multifaceted intervention with components to:

- Improve the identification of pregnancies at high risk of preterm birth - Provide and facilitate the use of steroids

- Reduce neonatal mortality by 30% in preterm

newborns, compared to the standard delivery of care
Althabe F, Belizan JM, Mazzoni et al. Reproductive Health 2012, 9:22. http://www.reproductive-health-journal.com/content/9/1/22. Global Network for Womens and Childrens Health Research (NICHD)

ACT Trial
Cluster Randomized Controlled Trial

102 health regions (Home, Primary Health Centre, and Hospital births)
6 countries Argentina, Guatemala, India, Kenya, Pakistan, and Zambia

Components of the Intervention

Identification Gestational age assessment Use Preterm Kit

OR REFER

Obstetric Disk

Delivery by Birth Attendant

Family members 19% Physician 16%

TBA 37%
Nurse/ midwife 28%

Carlo et al. N Engl J Med. 362:614-23, 2010.

Three Key Messages From the Born Too Soon Care Group on Antenatal Corticosteroids
1
Focus on dexamethasone for now Both betamethasone and dexamethasone are effective, but dexamethasone is less expensive and more commonly available

Focus on facility use for now

Adopt a low threshold for giving

ANCS may be beneficial in many contexts, but current data supports hospital usage

The balance of risks is in favor of treatment side effects are minimal while potential benefit is substantial

Conclusions
1. ACS administration is the most effective intervention during pregnancy to reduce neonatal mortality
2. ACS administration is safe for the mothers and babies 3. Use of ACS is low in developing countries

200,000 deaths per year may be averted if antenatal corticosteroids use is increased to 50% during preterm labour

Supportive Environment Needed to Implement ACS as Best Practice (1)

Establish national service delivery guidelines/ protocols integrated into existing guidelines. Ensure functioning supply and delivery systems.

Incorporate updated ACS guidelines into preservice education for healthcare providers who administer ACS.
Engage professional associations of healthcare cadres.
USAID and MCHIP

Supportive Environment Needed to Implement ACS as Best Practice (2)

Provide in-service training on ACS administration for all healthcare providers. Strengthen antenatal screening to include information for all women with conditions such as preterm uterine contractions, preterm rupture of membranes, and symptoms of pre-eclampsia. Increase community awareness of the importance of preterm birth prevention and the signs of threatened preterm birth. Support the provision of essential newborn care after delivery and referrals for babies born prematurely.
USAID and MCHIP

THANKS!