17 November marks World Prematurity Day 2014, a global awareness day to highlight the burden of preterm births and inform on simple, cost-effective solutions to reduce deaths and disabilities due to preterm birth complications.
For pregnant women at risk of preterm birth, antenatal corticosteroids (ACS) are amongst the most effective hospital-based interventions to reduce newborn death. Giving ACS to a mother in preterm labour helps her baby speed up lung development and reduces the risk of newborn death.
The UN Commission on Lifesaving Commodities for Maternal and Child Health lists ANCS as one of the four lifesaving commodities for newborns, and the 2013 State of the World’s Mothers estimates that ACS treatment costs as little as half a US dollar and could save up to 340,000 newborn lives each year.
Until recently, health experts advocated the scale-up of ACS in low-income settings, where the burden of deaths from preterm complications is greatest and coverage of ACS is lowest.
However, recent evidence calls into question the safety and effectiveness of ACS use in resource-poor settings.
New research – what is best for mothers and babies?
On 15 October 2014, findings were published from a large-scale trial evaluating the safety and effectiveness of ACS in low-income and middle-income countries. Unexpectedly, results from the trial show increased overall newborn deaths and maternal infection with ACS use.
Read the full study here and read the brief from the UN Commission of Life Saving Commodities ACS Working Group here.
Based on this new evidence, the WHO is in the process of reviewing guidelines for ACS in low-income settings. In the meantime, the ACS working group recommends the following:
“ANCS should only be used for gestational age between 24-34 weeks, and only where the following three conditions can be met:
- Ability to accurately assess gestational age and determine risk of preterm birth.
- Adequate care available for preterm newborns (e.g. Resuscitation, Kangaroo Mother Care, adequate feeding support, treatment of infection, etc.)
- Reliable, timely and appropriate identification and treatment of maternal infection.”
These recommendations have important programmatic implications for those working on the ground to prevent deaths from premature birth. For example:
- Should health facilities be discouraged from using ACS unless these can meet these conditions?
- How many health facilities in low-income settings are currently able to meet these criteria?
- What alternatives are there for mothers at risk of preterm labour and without access to facilities offering ACS?
To understand how those on the ground are confronting these questions, we invited Donna Vivio, Senior Newborn Health Advisor at US Agency for International Development, and Tunde Segun, Country Director of Evidence for Action Nigeria, to share their experiences.
Donna Vivio: "The recent study on ACS in low income countries has brought home the important lesson that there is no magic bullet – not any ONE intervention – that will decrease newborn deaths from complications of preterm birth. The tools that are available are there to be used within a package for prevention, management and care, and need to be available across the continuum from household to community and through the various levels of the health care system.
The results of this study will continue to be analysed. It is anticipated that official global guidance on ACS will be forthcoming from the World Health Organization (WHO) as it is set to review these results and other evidence soon. As we await this guidance, interim recommendations have been communicated to USAID’s Missions around the world and its programs. These recommendations are based on the best evidence at this point, and based on the principle of “do no harm”.
Pending further clarification and guidance from WHO, USAID Missions and programs will assure that new and current ACS activities follow ACS initiation criteria, including use in the appropriate hospital settings where accurate assessment of gestational age can occur and appropriate care for preterm babies can be provided.Communication is key. USAID Missions will engage with Ministry of Health and other partners to discuss communication of this new information to programs/facilities, including ACS use in hospitals meeting the criteria.
USAID will continue to communicate with its Missions and programs with timely updates as new information and guidance are available."
Tunde Segun: "At the recently concluded Nigerian Newborn Health Conference, there was a plenary session on usage of ACS. The main conclusion was that in Nigeria, it shouldn’t be administered at any level lower than the teaching hospital, where the criteria of accurately determining gestational age, newborn resuscitation and treating maternal infections (as a result of the CS lowering immunity) can be guaranteed. Even though issues of missed opportunities at secondary level were raised, caution was the watchword."