Chomba: Antenatal Corticosteroids for Threatened Preterm Delivery

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    Antenatal Corticosteroids for

    Threatened Preterm Delivery

    Prof. Elwyn Chomba, MBChB, DCH, MRCP

    Permanent SecretaryMinistry of Community Health, Mother and Child Health,ZM

    Global Network for Womens and Childrens Health Research

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    Background

    Global health perspective

    Preterm birth (PTB) is the second leadingcause of Under-5 mortality, after pneumonia

    1.1 million children die from direct

    complications of preterm birth

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    Key evidence-based interventions during

    pregnancy and childbirth?

    Background

    Understand the gestational clock triggering

    the onset of labour

    Identify the causal pathways leading to

    preterm labour and delivery

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    Background

    However, until there is better understanding

    of the onset of labor and the causal

    pathways, improved management ofpreterm birth can reduce mortality and major

    morbidities

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    Key Evidence-Based Interventions

    for Threatened Preterm Delivery

    Antenatal corticosteroids to reducemortality and major morbidities (i.e., RDS)

    from prematurity

    Antibiotics for premature rupture ofmembranes (pPROM) to prevent severe

    morbidity

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

    Lawn et al, 2010

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    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, andneurodevelopmental impairment

    Roberts & Dalziel, 2006

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    Despite their effectiveness,antenatal corticosteroid use in low-

    and middle-income countries

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    Antenatal Corticosteroids Use

    During Preterm Labour100%

    80%

    10%5%

    30%4% - 71%

    HIC LMIC

    N=75

    LMIC

    N=42

    Latin

    America

    N=6

    Jones et al 2003

    Darmstadt et al 2005

    Born Too Soon report 2012

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    Why is such an effective, safe, easy

    to administer, and inexpensiveintervention is still underused in low-

    and middle-income countries?

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    Factors Related to the Underuse (1)

    Pending questions

    Is the effect similar at community level than

    at hospital level?

    Are they beneficial at therecommended/relevant gestational ages?

    Factors related to organization Lack of availability of the drug

    Difficulty in timely identification and treatment

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    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

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    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 careAlthabe 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)

    http://www.reproductive-health-journal.com/content/9/1/22http://www.reproductive-health-journal.com/content/9/1/22http://www.reproductive-health-journal.com/content/9/1/22http://www.reproductive-health-journal.com/content/9/1/22http://www.reproductive-health-journal.com/content/9/1/22http://www.reproductive-health-journal.com/content/9/1/22
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    ACT Trial

    Cluster Randomized Controlled Trial

    102 health regions (Home, PrimaryHealth Centre, and Hospital births)

    6 countries

    Argentina, Guatemala, India, Kenya,

    Pakistan, and Zambia

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    Components of the Intervention

    Identification Gestational ageassessment

    OR

    Use PretermKit

    REFER

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    Obstetric Disk

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    Delivery by Birth Attendant

    TBA

    37%

    Family members19%

    Physician

    16%

    Nurse/

    midwife28%

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

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    Three Key Messages From the Born Too Soon

    Care Group on Antenatal Corticosteroids

    Both betamethasone and dexamethasone

    are effective, but dexamethasone is less

    expensive and more commonly available

    ANCS may be beneficial in many contexts,

    but current data supports hospital usage

    The balance of risks is in favor oftreatment side effects are minimal while

    potential benefit is substantial

    Focus on

    dexamethasone

    for now

    Focus on facility

    use

    for now

    Adopt a lowthreshold for

    giving

    1

    2

    3

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    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

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    200,000 deaths per year may

    be averted if antenatalcorticosteroids use is increased

    to 50% during preterm labour

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    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 pre-

    service education for healthcare providers who

    administer ACS.

    Engage professional associations of healthcarecadres.

    USAID and MCHIP

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    Supportive Environment Needed to

    Implement ACS as Best Practice (2)

    Provide in-service training on ACS administration for allhealthcare providers.

    Strengthen antenatal screening to include information for

    all women with conditions such as preterm uterine

    contractions, preterm rupture of membranes, andsymptoms 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

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    THANKS!