Prevention of Maternal and Neonatal Death/Infections With a Single Oral Dose of Azithromycin in Women in Labor (in Low- and Middle-income Countries): a Randomized Controlled Trial
Phase: PHASE3
Conditions: Maternal Death, Maternal Infections Affecting Fetus or Newborn, Neonatal SEPSIS, Maternal Sepsis During Labor, Neonatal Death, Postpartum Sepsis
Sponsor: NICHD Global Network for Women's and Children's Health

Prevention of maternal and neonatal death/infections 
with a single oral dose of azithromycin in women in 
labor (in low- and middle-income countries): A 
randomized controlled trial 
ClinicalTrials.gov number: 
NCT03871491 
Lead Study Investigator(s): Alan T.N. Tita, MD, PhD, Center for Women’s Reproductive Health 
and Maternal-Fetal Medicine Division, UAB  
Wally Carlo, MD, Neonatology Division, UAB 
Elwyn Chomba, MBChB, DCH, MRCP, University Teaching Hospital 
Subcommittee Members:  
Marion Koso-Thomas, MD, NICHD 
Tracy Nolen, DrPh, RTI International 
Elizabeth McClure, PhD, RTI International 
Jennifer J. Hemingway-Foday, MPH, RTI International 
Funding: 
Eunice Kennedy Shriver National Institute of Child Health and 
Human Development and The Bill & Melinda Gates Foundation 
This document contains the following items: 
1. Final study protocol (V.1.6, dated 15 July 2022)-- See 
Appendix 2 for model informed consent form 
2. Final Statistical Analysis Plan (V.2.0, dated 13 October 2022)

Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
1 
Prevention of maternal and neonatal death/infections 
with a single oral dose of azithromycin in women in 
labor (in low- and middle-income countries): A 
randomized controlled trial 
 
ClinicalTrials.gov number: 
NCT03871491 
 
Lead Study Investigator(s): 
Alan T.N. Tita, MD, PhD, Center for Women’s Reproductive Health and 
Maternal-Fetal Medicine Division, UAB  
Wally Carlo, MD, Neonatology Division, UAB 
Elwyn Chomba, MBChB, DCH, MRCP, University Teaching Hospital 
  
 
Subcommittee Members:  
Marion Koso-Thomas, MD, NICHD 
 
 
 
 
 
Tracy Nolen, DrPh, RTI International 
 
 
 
 
Elizabeth McClure, PhD, RTI International 
 
 
 
 
Jennifer J. Hemingway-Foday, MPH, RTI International 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Version Number: 
Version 1.6 
 
Version Date: 
July 15, 2022 
 
Funding:  
Eunice Kennedy Shriver National Institute of Child Health and Human 
Development and The Bill & Melinda Gates Foundation 
 
 
 
 
 
 

Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
2 
Version Tracking 
Version 
Date 
Authors 
Comments 
1.0 
Sep 27, 2018 
A-PLUS WG 
This version will be used for IRB/ERC submissions. 
1.1 
Dec 19, 2018 
A-PLUS WG 
Internal version to document and review proposed revisions from GN investigators. 
1.2 
Dec 20, 2018 
A-PLUS WG 
and GN 
Investigators 
At request of GN investigators, revisions made to the following sections: Inclusion and exclusion criteria 
(Section 2.2); Consent procedures (Section 2.4); Description of data forms (Section 4.1); Sample informed 
consent form (Appendix 2); and in-text references.  
This version will be used for IRB/ERC submissions after December 20, 2018.  
1.3 
January 24, 
2020 
A-PLUS WG 
Revisions made based on feedback from pilot study and requests from GN investigators. The following 
sections have been revised:  
• Section 1 (Statement of Problem), including 1.2 and 1.3 (Primary and Secondary Specific Aims) and 1.5 
(Rationale/Justification) 
• Section 2 (Methods), including 2.1 (Inclusion Criteria); 2.4.7 (Monitoring after Discharge); 2.5 (Primary 
Outcomes); 2.6 (Other Maternal Outcomes); 2.7 (Other Neonatal Outcomes) and 2.8 (Safety Monitoring) 
• Section 3 (Analytical Plan) 
• Section 4.1 (Data Forms) 
• Section 5 (References) 
• Figure 1. Flowchart of Study Activities 
• Appendix 2. Sample Informed Consent 
• Appendix 3. Schedule of Study Procedures 
1.4 
January 29, 
2020 
A-PLUS WG 
Additional revisions made to: 
• Section 1.3 (Secondary Specific Aims) 
• Section 2.5 (Primary outcomes) 
• Section 2 (Methods), including 2.6 (Other Maternal Outcomes) and  2.7 (Other Neonatal Outcomes) 
• Section 3 (Analytical Plan, including 1.2 (Secondary Analysis-Women at High Risk for Infection Cohort) 
3.2.1 (Sample Size for Primary Outcome) and 3.2.2 (Sample Size for High-risk Women) 
This version will be submitted to IRBs/ERCs at all GN sites. 
1.5 
February 09, 
2021 
A-PLUS WG 
Updates made based on recommendations from the Data Monitoring Committee:  
• In Section 2.5 (Primary Outcome), removed urinary tract infection, omphalitis, eye infection, and skin 
infection from neonatal sepsis definition, removed fast breathing from the pSBI definition, and changed 
the pSBI fever criteria to 38 C/100.4 F.  
• In Section 2.7 (Other Neonatal Outcomes), added urinary tract infection, omphalitis, and fast breathing to 
the “other neonatal infection” outcome.  
Other updates:  
• In Section 3.5.1 (Reporting Adverse Events), made minor text changes to align with revised AE reporting 
procedures. [Refer to A-PLUS Technical Memo #2] 
• In Section 3.5.4 (Interim/Adverse Event Monitoring Plan), made minor text revisions to clarify that the 
interim analysis will be conducted in both the all-comers and high-risk cohort. This revision was made at 
the request of the Boston University IRB. 
• In list of Azithromycin Investigators, updated SFI for GN06-Guatemala to Manolo Mazariegos. 
This version will be submitted to IRBs/ERCs at all GN sites. 
1.6 
12 July, 2022 
A-PLUS WG 
High-risk definition updated to “Prolonged labor [≥18 hours] and/or prolonged membrane rupture [≥8 
hours]”. The following sections have been updated to reflect this change: 
• Abstract-Secondary Outcomes  
• Section 1.3 (Secondary Specific Aims) 
• Section 1.5 (Rationale/Justification) 
• Section 1.6.1 (The Gambian and Cameroon Trials) [Note: new reference added to this section, with full 
citation in reference list; as a result, all subsequent references have been renumbered] 
• Section 2.2.2 (Exclusion Criteria) 
• Section 3 (Analytical Plan) 
• Section 3.1.2 (Secondary Analysis-Women at High Risk for Infection Cohort) 
• Section 3.2.2 (Sample Size for High-risk Women) 
• Appendix 2 (Sample Consent) 
Other minor updates were made to the list of “Azithromycin Investigators” to reflect staffing changes since 
protocol V. 1.5 was released. 
This version will be submitted to IRBs/ERCs at all GN sites. 

Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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Table of Contents 
Azithromycin Investigators ...................................................................................................................... 6 
ACRONYMS ............................................................................................................................................. 9 
Abstract ................................................................................................................................................ 10 
1 
Statement of Problem ............................................................................................................. 11 
1.1 
Primary Hypotheses ................................................................................................................ 11 
1.2 
Primary Specific Aims .............................................................................................................. 11 
1.3 
Secondary Specific Aims .......................................................................................................... 11 
1.4 
Background ............................................................................................................................. 12 
1.4.1 Prevention of Maternal and Neonatal Deaths from Infections ........................................ 12 
1.4.2 Risks for Maternal and Neonatal Infections .................................................................... 12 
1.4.3 Intrapartum Azithromycin to Prevent Maternal and Neonatal Infection ......................... 13 
1.5 
Rationale/Justification ............................................................................................................. 13 
1.6 
Previous Studies ...................................................................................................................... 14 
1.6.1 The Gambian and Cameroon Trials ................................................................................. 14 
1.6.2 The US Trial and Cost Analysis ........................................................................................ 14 
1.6.3 Other Important Considerations .................................................................................... 15 
2 
Methods ................................................................................................................................. 16 
2.1 
Study Design ........................................................................................................................... 17 
2.2 
Study Population/Location ...................................................................................................... 17 
2.2.1 Inclusion Criteria ............................................................................................................ 17 
2.2.2 Exclusion Criteria ........................................................................................................... 17 
2.3 
Study Intervention and Comparison ........................................................................................ 18 
2.4 
Detailed Study Procedures ...................................................................................................... 18 
2.4.1 Community Sensitization................................................................................................ 18 
2.4.2 Screening ....................................................................................................................... 18 

Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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2.4.3 Consent ......................................................................................................................... 18 
2.4.4 Masking ......................................................................................................................... 19 
2.4.5 Randomization Procedures ............................................................................................ 20 
2.4.6 Monitoring before Discharge ......................................................................................... 20 
2.4.7 Monitoring after Discharge ............................................................................................ 20 
2.4.8 Sequence of Study Activities .......................................................................................... 21 
2.5 
Primary Outcomes ................................................................................................................... 22 
2.6 
Other Maternal Outcomes ...................................................................................................... 22 
2.7 
Other Neonatal Outcomes ....................................................................................................... 23 
2.8 
Safety Monitoring ................................................................................................................... 23 
2.9 
Site Preparation ...................................................................................................................... 24 
2.10 
Potential Risks and Benefits to Participants ........................................................................ 24 
3 
Analytical plan ......................................................................................................................... 25 
3.1 
Statistical Analysis Plan............................................................................................................ 25 
3.1.1 Primary Analyses ............................................................................................................ 25 
3.1.2 Secondary Analyses – Women at High Risk for Infection Cohort ..................................... 26 
3.1.3 Secondary Analyses – Other Secondary Outcomes ......................................................... 26 
3.2 
Sample Size ............................................................................................................................. 27 
3.2.1 Sample Size for Primary Outcome .................................................................................. 27 
3.2.2 Sample Size for High-Risk Women .................................................................................. 28 
3.3 
Available Population ................................................................................................................ 29 
3.4 
Projected Recruitment Time .................................................................................................... 29 
3.5 
Study Monitoring Plan ............................................................................................................. 29 
3.5.1 Reporting Serious Adverse Events .................................................................................. 29 
3.5.2 Method and Timing for Reporting Serious Adverse Events ............................................. 30 
3.5.3 Data Monitoring Plan and Stopping Rules ...................................................................... 30 
3.5.4 Interim/Adverse Event Monitoring Plan ......................................................................... 31 
3.5.5 Risks/Benefits ................................................................................................................ 32 
3.6 
Quality Control ........................................................................................................................ 32 

Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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3.6.1 Training.......................................................................................................................... 32 
3.6.2 Study Monitoring ........................................................................................................... 32 
3.6.3 Drug Quality Assurance and Monitoring ......................................................................... 32 
3.6.4 Plan for Sustaining Intervention ..................................................................................... 33 
4 
Data Management Procedures ................................................................................................ 33 
4.1 
Data Forms .............................................................................................................................. 33 
5 
References .............................................................................................................................. 35 
Appendix 1. Description of Participating Global Network Sites ............................................................... 38 
Appendix 2. Sample Informed Consent .................................................................................................. 40 
Appendix 3. Schedule of Study Procedures ............................................................................................ 44 
 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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AZITHROMYCIN INVESTIGATORS 
Central Team: Global Network Site 03 (Zambia) 
Waldemar A. Carlo, MD 
Principal Investigator 
University of Alabama at Birmingham 
Birmingham, Alabama 
wcarlo@peds.uab.edu 
 
Alan T.N. Tita, MD, PhD 
Azithromycin Protocol Lead Investigator 
University of Alabama at Birmingham 
Birmingham, Alabama 
atita@uabmc.edu 
Elwyn Chomba, MBChB, DCH, MRCP 
Senior Foreign Investigator 
University Teaching Hospital 
Lusaka, Zambia 
chombaelwyn@gmail.com 
Site Investigators 
Global Network Site 02 (Democratic Republic of Congo) 
Carl Bose, M.D. 
Principal Investigator 
University of North Carolina School of Medicine 
Chapel Hill, North Carolina 
cbose@med.unc.edu  
Antoinette Tshefu, MD, PhD, MPH  
Senior Foreign Investigator 
Kinshasa School of Public Health 
antotshe@yahoo.com 
Global Network Site 03 (Zambia) 
Wally Carlo, MD 
Principal Investigator 
University of Alabama at Birmingham 
Birmingham, Alabama 
Wcarlo@PEDS.UAB.EDU 
Elwyn Chomba, MBChB, DCH, MRCP 
Senior Foreign Investigator 
University Teaching Hospital 
Lusaka, Zambia 
chombaelwyn@gmail.com 
Global Network Site 06 (Guatemala) 
Nancy Krebs, MD 
Principal Investigator 
UCHSC 
Denver, Colorado 
Nancy.krebs@ucdenver.edu 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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Manolo Mazariegos, MD  
Senior Foreign Investigator 
INCAP 
Guatemala City, Guatemala 
mmazariegos@incap.int 
Global Network Site 07 (Bangladesh) 
William Petri, MD 
Principal Investigator 
University of Virginia 
Charlottesville, Virginia 
wap3g@virginia.edu 
Rashidul Haque, MD 
Senior Foreign Investigator 
ICDDR,B 
Dhaka, Bangladesh 
rhaque@icddrb.org 
Global Network Site 08 (Belagavi, India) 
Richard Derman, MD, MPH 
Principal Investigator 
Thomas Jefferson University 
Philadelphia, PA 
richard.derman@jefferson.edu  
Shivaprasad S. Goudar MD, MHPE 
Senior Foreign Investigator 
KLE University’s J N Medical College 
Belgaum, India 
sgoudar@jnmc.edu 
Global Network Site 09 (Pakistan) 
Robert L. Goldenberg, MD 
Principal Investigator 
Columbia University 
New York, New York 
rlg88@columbia.edu 
Sarah Saleem, MD 
Senior Foreign Investigator 
Aga Khan University 
Karachi, Pakistan 
sarah.saleem@aku.edu 
Global Network Site 11 (Nagpur, India) 
Patricia L. Hibberd, MD, PhD 
Principal Investigator 
Boston University 
Boston, Massachusetts  
 plh0@bu.edu  
Archana Patel, MD, DNB, MSCE, PhD 
Senior Foreign Investigator 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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Lata Medical Research Foundation 
Nagpur, India 
Dr_apatel@yahoo.com 
Global Network Site 12 (Kenya) 
Ed Liechty, MD 
Principal Investigator 
Indiana University School of Medicine 
Indianapolis, Indiana 
eliecht@iupui.edu 
Fabian Esamai, MBChB, MMed, MPH, PhD 
Senior Foreign Investigator 
Moi University School of Medicine 
Eldoret, Kenya 
fesamai2007@gmail.com 
National Institute of Child Health and Human Development (NICHD) 
Marion Koso-Thomas, MD, MPH 
Medical Officer, Global Network for Women’s and Children’s Health  
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) 
kosomari@mail.nih.gov 
RTI International 
Elizabeth McClure, PhD 
Principal Investigator, Data Coordinating Center 
RTI International, Durham, NC 
 
mcclure@rti.org 
Tracy Nolen, DrPh 
Senior Statistician, Data Coordinating Center 
tnolen@rti.org 
Jennifer J. Hemingway-Foday, MPH, MSW 
Protocol Manager for Azithromycin Protocol, Data Coordinating Center 
hemingway@rti.org 
 
 
 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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ACRONYMS 
AC 
 
All-comers 
ACOG  
American Congress of Obstetricians and Gynecologists  
ANC 
 
Antenatal Care 
BP 
 
Blood pressure 
DCC 
 
Data Coordinating Center 
DMC 
 
Data monitoring committee 
DMS 
 
Data Management System 
DRC 
 
Democratic Republic of Congo 
ERC 
 
Ethical review Committee 
FIGO 
 
International Federation of Gynecology and Obstetrics 
FDA 
 
Food and Drug Administration 
GA 
 
Gestational age 
GI 
 
Gastrointestinal  
GN 
 
Global Network for Women’s and Children’s Health Research 
HR 
 
High-risk 
IRB 
 
Institutional Review Board 
JAMA  
Journal of the American Medical Association 
ITT 
 
Intention to treat 
LIC 
 
Low-income country 
LMIC 
 
Low- and middle-income countries 
LMP 
 
Last menstrual period 
MNH 
 
Maternal and Newborn Health 
NEJM  
New England Journal of Medicine 
NICHD  
Eunice Kennedy Shriver National Institute of Child Health and Human Development 
NIH 
 
National Institutes of Health 
NNT 
 
Number needed to treat 
OHRP  
U.S. Office of Research Protections  
PI 
 
Principal Investigator 
pSBI 
 
possible serious bacterial infection 
RCT 
 
Randomized controlled trial 
RTI 
 
Research Triangle Institute International 
SAE 
 
Serious adverse event 
SC 
 
Steering Committee 
SFI 
 
Senior Foreign Investigator 
SMFM  
Society for Maternal-Fetal Medicine 
UAB 
 
University of Alabama at Birmingham 
WHO 
 
World Health Organization 
 
 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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ABSTRACT 
Background: Maternal and neonatal infections are among the most frequent causes of maternal and 
neonatal deaths, and current antibiotic strategies have not been effective in preventing many of these 
deaths. Recently, a randomized clinical trial conducted in a single site in The Gambia showed that 
treatment with oral dose of 2 g azithromycin vs. placebo for all women in labor reduced certain 
maternal and neonatal infections. However, it is unknown if this therapy reduces maternal and neonatal 
sepsis and mortality.  
Hypotheses: The trial includes two primary hypotheses, a maternal hypothesis and a neonatal 
hypothesis. First, a single, prophylactic intrapartum oral dose of 2 g azithromycin given to women in 
labor will reduce maternal death or sepsis. Second, a single, prophylactic intrapartum oral dose of 2 g 
azithromycin given to women in labor will reduce intrapartum/neonatal death or sepsis. 
Study Design Type: Randomized, placebo-controlled, parallel multicenter clinical trial. Women in labor 
will be randomized with one-to-one ratio to intervention/placebo.  
Population: Pregnant women in labor at ≥28 weeks gestational age with a live fetus pregnancy who plan 
to deliver vaginally in a facility. Women with evidence of chorioamnionitis or other infection requiring 
antibiotic therapy (not prophylaxis) at time of eligibility, allergy to azithromycin, use of azithromycin, 
erythromycin or other macrolide within 3 days of enrollment, known arrhythmia or cardiomyopathy, or 
plan for cesarean section delivery prior to enrollment will be excluded.  
Intervention: A single, prophylactic intrapartum oral dose of 2 g azithromycin.  
Comparison: A single intrapartum oral dose of an identical appearing placebo 
Outcomes:  
Primary outcomes: 1) Incidence of maternal death or sepsis and 2) incidence of intrapartum/neonatal 
death or sepsis.  
Secondary outcomes: Individual components of the primary outcomes (maternal death, maternal sepsis, 
intrapartum/neonatal death, neonatal sepsis), neonatal death/sepsis, neonatal deaths due to sepsis, 
and all-cause neonatal death; the primary maternal and neonatal outcome in a high-risk for infection 
population; specific maternal infections; use of subsequent maternal antibiotic therapy; pyloric stenosis; 
health care resource utilization; culture-positive infections and resistance; in an ancillary surveillance 
study,  incidence of antimicrobial resistance and microbiome diversity.  
 
 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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1 STATEMENT OF PROBLEM 
1.1 
Primary Hypotheses  
This study will have two primary hypotheses, one with a maternal focus and one with a neonatal focus. 
First, a single, prophylactic intrapartum oral dose of 2 g azithromycin given to women in labor in low and 
middle-income settings will reduce maternal death or sepsis. Second, a single, prophylactic intrapartum 
oral dose of 2 g azithromycin given to women in labor in low and middle-income settings will reduce 
intrapartum/neonatal death or sepsis.  
1.2 
Primary Specific Aims 
To test the effectiveness of a single dose of prophylactic intrapartum azithromycin compared to placebo 
in reducing the risk of the composite outcome of maternal death or sepsis. To separately test the 
effectiveness of a single oral dose of intrapartum azithromycin prophylaxis (2 g) compared to placebo in 
reducing the risk of the composite outcome of intrapartum/neonatal death or sepsis. Both groups will 
receive the routine or usual care provided at the facility during and after labor. 
1.3 
Secondary Specific Aims 
The single dose of intrapartum azithromycin prophylaxis (2 g) will be compared to placebo to accomplish 
the following secondary aims:  
• 
Main Secondary Aim for Women at High-Risk for Infection Cohort:  
a. To evaluate whether the risk of maternal death or sepsis differs among laboring women 
with and without high-risk for infection (high risk is defined as women with prolonged labor 
[≥18 hours] and/or prolonged membrane rupture [≥8 hours] at time of randomization). 
• 
Other secondary specific Aims: 
b. To evaluate the effectiveness in reducing the risk of individual components of the primary 
composite endpoints (i.e., maternal death, maternal sepsis, intrapartum/neonatal death, 
neonatal sepsis including specifically all-cause neonatal deaths and neonatal deaths due to 
sepsis).  
c. To evaluate the effectiveness on the risk of intrapartum/neonatal death or sepsis in infants 
of laboring women at high-risk for infection because of prolonged labor (≥18 hours) and/or 
prolonged membrane rupture (≥8 hours). 
d. To evaluate the effectiveness on the risk of maternal infections including clinical 
chorioamnionitis, endometritis, wound infections (perineal or Cesarean), abdominal or 
pelvic abscess, mastitis/breast abscess or infection, pyelonephritis, pneumonia and other 
bacterial infections in all laboring women as well as in those at high-risk for infection. 
e. To evaluate the effectiveness in reducing the use of subsequent maternal antibiotic therapy 
from randomization to 42 days postpartum for any reason in all laboring women as well as 
in those at high-risk for infection. 
f. To compare the use of health care resources. Use of health care resources will be measured 
in terms of maternal and neonatal duration of hospital stay, unscheduled visits, readmission, 
and admission to special care units/intensive care units in all laboring women and newborns 
as well as in those at high-risk for infection.  
g. To assess maternal GI symptoms (e.g., nausea, vomiting, and diarrhea) and other reported 
side effects, as well as infant pyloric stenosis and type of culture positive infections 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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(antimicrobial resistance and maternal and infant microbiome diversity are compared in an 
ancillary study).  
h. To determine whether the effect on each of the primary outcomes differs by region (Africa, 
Latin America or Asia), any other antibiotic use during labor, and mode of delivery (cesarean 
or vaginal). Note that antibiotic use will not include use to treat any infections diagnosed 
after randomization as those will be outcomes. 
1.4 
Background 
Maternal and neonatal infections are among the most frequent causes of maternal and neonatal 
death. Maternal infection during pregnancy and the puerperium account for approximately 10% of the 
global burden of maternal deaths. This places maternal infection among the top five causes of maternal 
mortality worldwide.1 Neonatal infection is the third most common cause of neonatal mortality and 
accounts for about 16% of neonatal mortality worldwide.2 Furthermore, maternal and neonatal deaths 
from infections are not decreasing compared with deaths from other frequent causes of mortality.1,2 
There is a need for innovative simple effective interventions that can be scaled up to reduce the burden 
of both maternal and neonatal mortality due to infections.  
1.4.1 
Prevention of Maternal and Neonatal Deaths from Infections  
Current strategies to prevent maternal and neonatal deaths from infections are insufficient. Current 
approaches to prevention, identification, and treatment of neonatal sepsis have had limited impact. 
According to the WHO, maternal deaths from infection have remained unchanged or increased in some 
instances, whereas deaths from other causes have reduced. The evidence backing current WHO 
guidelines for prevention and treatment of peripartum infections is generally graded as low or very low 
quality.1 Efforts for early identification and treatment of neonatal infection are important but neonatal 
deaths due to infection continue to be very prevalent. Recent studies of alternative antibiotic regimens 
that do not require a full course of intravenous antimicrobial therapy have shown comparable 
effectiveness but have not reduced deaths from infections.3-6 Among research priorities, a WHO 
guideline panel identified the evaluation of the role of routine prophylactic antibiotics in women who 
undergo a normal vaginal birth as well as in those at high risk for infection due to prolonged labor or 
membrane rupture.1 
1.4.2 
Risks for Maternal and Neonatal Infections  
Maternal and neonatal infections by maternal risk including cesarean delivery. While the role of 
antibiotic prophylaxis for cesarean delivery is well-established, in many low-resource settings, many 
maternal infections occur after vaginal deliveries with high-risk for infections. Cesarean delivery 
especially after labor or membrane rupture is the strongest risk factor for maternal peripartum infection 
including endometritis, wound infection and sepsis (increasing risk by up to 5 to 10 times compared to 
vaginal delivery).7 The fraction of maternal infection attributable to cesarean delivery is rather low 
because of the low cesarean delivery rate of 5-10% or lower, especially in the Africa region, compared 
with 20-30% or higher in the US and many high income countries.8 Therefore, strategies that address 
maternal peripartum infection and sepsis in the developing world should focus as well on identifying and 
preventing (as well as treating) infection in women who have a vaginal birth, particularly those who are 
at high-risk. There is an increased risk of infection in women who undergo prolonged labor ≥18 hours (at 
least 2 fold) or membrane rupture ≥6 hours (at least 2-3 fold) compared to women who do not 
experience these risk factors.1 These risk factors identify a large group of women who are at the highest 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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risk for maternal peripartum infections (including chorioamnionitis, endometritis, perineal wound 
infection and post-cesarean surgical site infections) and sepsis after a vaginal or cesarean delivery and 
also place newborns at increased risk for sepsis. However, even though 80-90% of pregnancies in labor 
are not at this highest-risk for infection depending on criteria used, they may account for about 50% of 
maternal and neonatal infections in LMICs. Thus, testing antibiotic strategies during labor in LMICs 
should include both the high-risk and lower risk women as highlighted in research priorities from the 
WHO guideline panel.1 
Antibiotic Prophylaxis for Women who deliver by Cesarean section. The appropriate use of antibiotic 
prophylaxis for cesarean delivery and antiseptic agents are among the most effective preventive 
interventions as highlighted by the WHO guidelines for maternal peripartum infections.1 Antibiotic 
prophylaxis, preferably prior to incision, in particular, among several strategies, effectively reduces the 
risk of infection and the associated high health care and personal costs.1,9-11 However, the prevalence of 
cesarean sections is low, in many low-resource settings, particularly in sub-Saharan Africa, and thus, do 
not account for the large burden of the maternal and neonatal infections worldwide.  
1.4.3 
Intrapartum Azithromycin to Prevent Maternal and Neonatal Infection 
Azithromycin: a novel approach to maternal and neonatal infections. A novel approach to maternal 
and neonatal infection is to target organisms that may be very frequent pathogens but that historically 
have not been the target of antimicrobial treatment.12 A multicenter randomized clinical trial (RCT) of 
azithromycin prophylaxis added to the standard prophylactic regimen (cephalosporin) in women who 
underwent cesarean delivery following labor or membrane rupture for at least 4 hours in the US showed 
that maternal infection was reduced by about 50%.13 A single center RCT in a low-income country (LIC) 
setting suggested that azithromycin prophylaxis may improve maternal and neonatal outcomes. In an 
RCT in The Gambia that included all women in labor, treatment with 2 g of azithromycin vs. placebo 
before delivery reduced maternal and neonatal infections.14 Therefore, we propose to evaluate the 
effectiveness of a single oral dose of azithromycin as an intrapartum prophylactic agent for maternal 
and neonatal infection and death. We will also monitor the potential side effects of this intervention. 
1.5 
Rationale/Justification 
Maternal infection and sepsis is a priority to reduce maternal and neonatal deaths. Compared to 
postpartum hemorrhage and preeclampsia/eclampsia, maternal infection has received less attention as 
a major cause of maternal death; proportionally it accounts for increasing deaths.1 The WHO and other 
global health authorities identified maternal infection/sepsis as a priority problem to reduce maternal 
deaths. In addition, maternal infection significantly increases the risk of neonatal sepsis which is one of 
the leading causes of neonatal death in LICs.15 Most recently, a NEJM perspective article highlighted the 
WHO resolution issuing a clarion call recognizing “Sepsis” as a global health priority.16 Drawing from our 
findings on azithromycin prophylaxis for cesarean delivery in the US13 and data from another preliminary 
trial in The Gambia, Africa,14 we propose to evaluate the role of a single oral dose of azithromycin (plus 
usual care) to prevent maternal death or peripartum sepsis and intrapartum/neonatal death or sepsis in 
laboring women as well as the targeted sub-population of those at the highest risk for infection because 
they have prolonged labor (≥18 hours) and/or prolonged membrane rupture (≥8 hours).  
Azithromycin is available as a generic agent with easy storage requirements. It has a bimodal half-life of 
up to 70 hours in the non-pregnant population. Although its pharmacokinetic characteristics are not as 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
14 
well studied in the pregnant population, it is commonly used during pregnancy for treatment of 
chlamydia and other infections. Azithromycin covers a broad spectrum of bacteria (including gram-
positive cocci, genital ureaplasmas and mycoplasmas, and certain gram-negative bacilli and anaerobes) 
that are associated with maternal infections which are often polymicrobial (chorioamnionitis, 
endometritis, and perineal/cesarean wound infection) and sepsis. In addition to the aforementioned 
organisms which may play a role in neonatal infection, azithromycin also has activity against Group B 
streptococcus which is a major cause of neonatal sepsis in developed countries and may be implicated in 
LICs and low-resources settings as well. Therefore, a successful prophylaxis intervention is likely to 
reduce infections and death and may also reduce health care costs and need for prolonged antibiotic 
therapy to treat infections which may be associated with resistance. Indeed, the recent WHO Guidelines 
on peripartum infection articulated the following among research priorities: what are the benefits of 
initiating prophylactic antibiotics among women undergoing uncomplicated vaginal birth and among 
those at high risk such as after prolonged rupture of membranes?1 A JHPIEGO consultative meeting on 
enhancing the focus on maternal infections suggested that "Attention to identification and prompt 
management of prolonged labor and prolonged rupture of membranes is critical to reduce disease and 
death due to maternal sepsis."15,16,17  
1.6 
Previous Studies 
1.6.1 
The Gambian and Cameroon Trials 
Data from a single center trial in a LIC setting suggest the potential for azithromycin prophylaxis to 
improve maternal and neonatal outcomes. Among 829 Gambian mothers (randomized to 2 g of 
azithromycin vs. placebo before delivery) and their 830 newborns, maternal infections were lower in the 
azithromycin group (3.6% vs 9.2%; relative risk [RR], 0.40; 95% confidence interval [CI], 0.22-0.71; P = 
0.002).14 Among newborns, the overall prevalence of infections was also lower in the azithromycin 
group (18.1% vs 23.8%; RR, 0.76; 95% CI, 0.58-0.99; P = 0.052).14 Maternal and neonatal carriage of 
infectious organisms was lower in the azithromycin group.18 A test of concept trial focusing on high-risk 
women in Cameroon (labor ≥18 hours or membrane rupture ≥8 hours at randomization was 
underpowered by suggested lower maternal infection in women who received azithromycin.19  
1.6.2 
The US Trial and Cost Analysis 
In a multicenter US RCT, it was demonstrated a further 50% reduction in the risk of maternal peripartum 
infection by adding a single 500 mg intravenous dose of azithromycin to the standard prophylactic 
regimen (a single intravenous dose of cefazolin 1-2 g or ampicillin) in the highest-risk group of women 
who undergo cesarean delivery following labor or membrane rupture for at least 4 hours.13 These results 
were observed despite universal use of other antibiotics in both arms of the trial. Specifically, the 95% 
without penicillin allergy had a cephalosporin (mainly cefazolin) for usual cesarean prophylaxis; the 
remainder that gentamicin and clindamycin. In addition, 25-30% received a penicillin for GBS 
prophylaxis.  Infection was significantly lower in the azithromycin group compared to the placebo group; 
6.1% vs. 12%; RR =0.51 (95 % CI 0.38 to 0.68); p<0.001. Specifically, adjunctive azithromycin use was 
associated with significant reductions in the risks of endometritis (3.8% vs. 6.1%, RR=0.62, 95% CI: 0.42-
0.92; p=0.02) and wound infections (2.4% vs. 6.6%, RR=0.35, 95% CI: 0.22-0.56; p<0.001). The number 
needed to treat (NNT) to prevent one infection was 17 for any infection, 43 for endometritis and 24 for 
wound infection. Other maternal outcomes including need for readmission or unscheduled visits for any 
reason or specifically for infection (decreased by up to 50%), serious adverse events, postpartum fever, 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
15 
or subsequent treatment with antibiotics were also significantly less common with azithromycin 
prophylaxis. Short-term perinatal/infant outcomes including deaths, sepsis, and other serious neonatal 
morbidities were rare in this developed country population and did not differ between groups.13 In a 
related cost-analysis report, it was estimated that use of adjunctive azithromycin saves approximately 
$360 for each use in unscheduled (high-risk) cesarean deliveries such as those studied in the RCT and 
$143 per use in scheduled or pre-labor cesarean delivery.20 The results suggesting cost-savings were 
robust across wide ranges of baseline risk of infection and treatment effect size.20Thus, in the US alone, 
adjunctive azithromycin prophylaxis for cesarean delivery could lead to $350M in cost-savings/year due 
to avoided infection. These works built upon, and are supported by, over 20 years of research on 
maternal infections at UAB and elsewhere.21-31 Azithromycin provides coverage against the most 
common pathogens identified in association with peripartum infections including genital mycoplasmas 
and ureaplasmas (when specific methods are utilized to identify them). 
1.6.3 
Other Important Considerations 
A recurrent concern regarding the potential routine use of azithromycin in a large population is 
antibiotic resistance. Monitoring for characteristics suggestive of resistant infection will be important to 
incorporate in the protocol. However, a number of factors mitigate concerns about antibiotic resistance: 
(a) the design of the trial using a single prophylactic dose (as opposed to recurrent treatment doses) of 
antibiotic, (b) surveillance of maternal clinical cultures up to 6 weeks in the trial in cesareans in the US 
revealed that positive wound cultures overall and those positive for resistant organisms were 
significantly less frequent in the azithromycin group;13 (c) if successful, prophylaxis will reduce the risk of 
infection and actually reduce the overall frequency of use of antibiotics to treat infection (a result in the 
US trial as stated above). It is estimated that women in the high-risk for infection group as defined will 
account for about 10-20% of laboring women. In principle, the use of single prophylactic dose (as 
opposed to multiple) minimizes the likelihood of antimicrobial resistance but samples will be taken to 
determine antimicrobial resistance.32  
Azithromycin is currently recommended to treat or prevent several infections in pregnancy including 
gonorrhea (1 g po), chlamydia (1 g po), and Mycobacterium avium complex prophylaxis (600 mg 
twice/week or 1.2 g weekly po). Azithromycin is sometimes used for perioperative prophylaxis in 
patients at risk for endocarditis (500 mg po). Considering the success with a single dose of 2 g in the 
Gambian trial, our success with 500 mg IV for cesarean prophylaxis, and the 40% bioavailability of oral 
azithromycin, we propose to use 2 g po of azithromycin for the proposed intervention. The best 
approach to this evaluation in order to influence future uptake into clinical practice is an RCT. The 
primary maternal outcome will be maternal death or sepsis within 42 days after delivery. The primary 
neonatal outcome will be intrapartum/neonatal death or sepsis within 28 days after birth (defined by 
WHO criteria).33  
Azithromycin is pregnancy category B – animal studies using maternally toxic doses showed no fetal 
harm. Limited studies suggest azithromycin is excreted in human milk in a sustained fashion.34 There are 
no specific drug-drug interactions warranting dose adjustments when given with other medications. 
Elimination is by both hepatic and renal route, and no specific adjustments are mandated for patients 
with renal or hepatic insufficiency. The long elimination 1/2-life of 68 hours is due to extensive uptake 
and subsequent release of drugs from tissues. The only absolute contraindications are rare: known 
hypersensitivity reaction to azithromycin, erythromycin or other macrolide antibiotic or history of 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
16 
cholestatic jaundice due to azithromycin. Potential adverse events include very rare (<1%) allergic 
hypersensitivity (mild and severe skin reactions – Stevens Johnson Syndrome and toxic epidermal 
necrolysis, angioedema and anaphylaxis) and clostridium difficile-associated diarrhea. With multi-day 
azithromycin therapy, 0.6% of patients discontinued azithromycin due to side effects. With single 1-2 
gram doses, gastrointestinal symptoms (nausea 5-18%, diarrhea/loose stools 7-14%, abdominal pain 5-
7%, vomiting 2-7%, and dyspepsia 1%) as well as vaginitis 2% and dizziness (1%) were the most 
commonly reported side effects. No other side effect occurred with a frequency greater than 1%. 
Azithromycin has been associated with hypertrophic pyloric stenosis in some observational studies. In a 
retrospective study, oral azithromycin exposure during the first 14 days after birth was associated with 
an increased incidence of pyloric stenosis.35 However, an increased risk of pyloric stenosis was not 
reported in infants following a single dose of azithromycin to women in labor in randomized trials in the 
US and Gambia.13-14, 16 The much larger sample size of the proposed study affords the opportunity to 
further explore this question. 
The FDA in 2013 issued an advisory regarding concerns about potential for rare life-threatening 
arrhythmias with azithromycin use particularly among those with preexisting cardiovascular risk. The 
information was based on an observational study of older, ill patients who received multiple courses of 
oral azithromycin over 5 days.36 The findings are not applicable to our current study population for 
several reasons: the population is much younger, generally without cardiac co-morbidities, a single dose 
rather than cumulative doses of oral azithromycin over 5 days is being studied, additional studies of 
younger, healthy patients did not suggest an increased cardiovascular risk37; and patients with 
arrhythmia or known history of cardiomyopathy will be excluded. In addition, the prior study of 2013 
women in the US did not suggest a cardiovascular safety signal, and the potential reduction in severe 
infection may exceed the excess risk of severe arrhythmia with a single dose of azithromycin.13   
2 METHODS 
Pregnant women in labor at study health facilities who appear to be ≥28 weeks gestational age by best 
clinical estimate with a live fetus pregnancy will be screened for eligibility (see Section 2.2) by research 
staff starting at the time of admission and continuously during the hospitalization. Gestational age will 
be determined using the “best estimate” algorithm that is currently used in the GN MNH registry. Those 
eligible will be consented. Those consented will be randomized to receive a single dose of azithromycin 
2 g or identical placebo to be given and directly observed during labor. Because of the ease of storage of 
azithromycin, sequentially prepared medications in identical packages following the randomization 
sequence will be available and dispensed by the study staff. The rest of the care will be provided 
according to the local standard of care. Women will be followed up until discharge and surveillance 
maintained (in-person), with visits at 3 days, 7 days, and 42 days after delivery as has generally been 
done in the Global Network to ascertain study outcomes.  
We will apply the recently recommended “simple and actionable” WHO definition of sepsis in a 2017 
statement endorsed by multiple international organizations. The definition of sepsis includes a suspicion 
of infection and the presence of organ dysfunction based on clinical findings.15 
To further ensure more objective ascertainment of the sepsis outcome, we propose that the DCC will 
prospectively define a process for defining criteria for a masked centralized review and adjudication of all 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
17 
cases of infection to ensure conformity with the proposed definition. This approach of adjudication is 
applied to validate infection in many trials including our recently completed ASPIRIN trial.38 This 
approach to adjudication has some similarities to the near-miss classification for adjudication in women 
delivering in the Global Network sites that was done recently.39 
2.1 
Study Design  
This study is a masked, placebo-controlled RCT. The investigational regimen is 2 g of azithromycin and 
the comparison arm is an identical placebo which is given orally. Both groups will also receive the 
standard of care during labor, delivery and postpartum per local standards.  
2.2 
Study Population/Location 
Pregnant women laboring in health facilities of the eight Global Network sites/other health facilities will 
be eligible. The Global Network sites are described in Appendix 1. Health facilities may include any 
hospitals and health centers where women routinely deliver within the study sites.     
2.2.1 
Inclusion Criteria 
• 
Pregnant women in labor ≥28 weeks GA (by best estimate) with a pregnancy with one or more 
live fetuses who plan to deliver vaginally in a facility.  
• 
Admitted to health facility with clear plan for spontaneous or induced delivery. 
• 
Live fetus must be confirmed via presence of a fetal heart rate prior to randomization.  
• 
≥18 years of age or minors 14-17 years of age in countries where married or pregnant minors (or 
their authorized representatives) are legally permitted to give consent. 
• 
Have provided written informed consent [Note: written informed consent may be obtained 
during antenatal care, but verbal re-confirmation may be needed (per local regulations) at the 
time of randomization]. 
2.2.2 
Exclusion Criteria  
• 
Non-emancipated minors (as per local regulations) 
• 
Evidence of chorioamnionitis or other infection requiring antibiotic therapy at time of eligibility 
(however, women given single prophylactic antibiotics with no plans to continue after delivery 
should not be excluded).  
• 
Arrhythmia or known history of cardiomyopathy. 
• 
Allergy to azithromycin or other macrolides that is self-reported or documented in the medical 
record. 
• 
Any use of azithromycin, erythromycin, or other macrolide in the 3 days or less prior to 
randomization.  
• 
Plan for cesarean delivery prior to randomization. 
• 
Preterm labor undergoing management with no immediate plan to proceed to delivery.  
• 
Advanced stage of labor (>6 cm or 10 cm cervical dilation per local standards) and pushing or 
too distressed to understand, confirm, or give informed consent regardless of cervical dilation. 
• 
Are not capable of giving consent due to other health problems such as obstetric emergencies 
(for example, antepartum haemorrhage) or mental disorder. 
• 
Any other medical conditions that may be considered a contraindication per the judgment of 
the site investigator. 
• 
Previous randomization in the trial. 

 
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18 
Sites may choose to obtain written consent during antenatal care from pregnant women of the age of 
consent who plan to deliver vaginally in a facility and have no known medical exclusions. In this case, 
study staff must fully assess and confirm eligibility at the time of randomization. It may also be 
necessary to verbally re-confirm consent at the time of randomization, if required by local regulations. If 
it is determined that the study needs to be extended to accrue the planned sample size for HR cohort, 
then women who deliver prior to meeting HR criteria for randomization will be excluded.   
2.3 
Study Intervention and Comparison 
The study intervention is a single 2 g dose of directly observed oral azithromycin, to be administered as 
four 500 mg pills or tablets directly after randomization. By random allocation, participants will receive 
2 g of oral azithromycin vs. placebo. We will design the placebo with the assistance of a reputable 
pharmacy/pharmaceutical company, using identical capsules or pills containing azithromycin 2 g or a 
matching placebo (non-antimicrobial agent) to accomplish masking. All of the participants’ obstetric care 
will be similar for all both arms and consist of the routinely available care at each center. 
2.4 
Detailed Study Procedures 
2.4.1 
Community Sensitization 
Local health providers will receive sensitization about the study to foster communication and 
collaboration at the facilities where enrollment will take place. In addition, pregnant women and their 
families in the enrollment area will receive information about the study during antenatal care (ANC) 
visits to facilitate recruitment and comprehension during the consenting process. Sites may choose to 
consent women during these sensitization sessions, prior to labor; however, confirmation of eligibility 
and consent will be required during the screening process described in Section 2.4.2 and 2.4.3.  
2.4.2 
Screening 
Women in labor in defined health facilities (both hospitals and health centers) will be identified by 
research staff. A brief review of eligibility will be made to determine whether the patient is in labor and 
does not meet any of the exclusion criteria. If a contraindication to participation in the trial is found, the 
woman will be excluded from the trial at this point.  
2.4.3 
Consent 
Before a woman participates in the trial, the research staff must obtain her informed consent to 
voluntarily take part in the study. Consent will be obtained from women ≥18 years of age or minors 14-
17 years of age in countries where married or pregnant minors (or their authorized representatives) are 
legally permitted to give consent. When enrolling minors, we will follow the in-country policies for 
human research protection and the guidelines approved by the local ethical review committees (ERCs). 
In the case of pregnant minors, this may require that written consent is obtained from her 
parents/guardians or husband, with written assent from the minor.  
Potential participants will be screened and enrolled in the study upon admission for delivery; therefore, 
consent will be obtained during labor. Consent should be obtained as early as possible during the 
intrapartum period and must be obtained prior to the cervical dilation limit approved by local 
authorities (e.g. either > 6 cm or 10 cm) and/or pushing, as assessed from clinical exam by health facility 
staff. It is not feasible to wait because the intervention must be given before delivery. Research sites 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
19 
may choose to obtain initial consent during ANC; however, in this situation, confirmation of consent will 
be required during the screening and enrollment process.  
If consent is obtained during labor, study staff will make necessary accommodations to ensure that the 
laboring women can comprehend the information presented during the consent process. Potential 
participants who present in labor can take as much time as needed to consider participation while in 
labor and will be able to discuss the study with family/friends if desired before deciding on participation. 
If the participant cannot read, the form will be read aloud to her by a person unaffiliated with the study. 
Alternatively, the Research Coordinator or a designate may read the consent, but in the presence of a 
witness who is unaffiliated with the research study. Potential participants will be given an opportunity to 
discuss the study procedures and ask questions. Additional details are provided in the study Manual of 
Procedures. 
Fair balance will be maintained while describing the risks and benefits of participation in the study. No 
undue pressure will be placed on the potential participant to enroll in the trial. It will further be 
explained that lack of participation will not affect the usual and anticipated standard of care. As the 
literacy levels will vary and may be a challenge, the consent process will include a verbal review of the 
consent form. 
After the potential participant has read the consent form, but before she signs, the research staff will 
show her a sample study pill and confirm that she is willing and able to take the study pill as prescribed. 
Only if she is willing to commit to taking the pill will she be enrolled; otherwise, this will be recorded as a 
refusal of consent. Following review of the consent, the potential participant (or parent/guardian) will 
be asked to sign the form. If the potential participant (or parent/guardian) is unable to sign her name, 
she will be asked to use her thumbprint to indicate written approval. In both cases, the unaffiliated 
person will also sign the consent form. Both the research staff and the study participant retain signed 
copies of the form.  
An eligible woman may refuse to participate in the trial at the time of recruitment. This will be recorded 
in the Screening and Recruitment Form. She may also choose to withdraw from the study at any time 
after enrollment. This will be recorded on the Withdrawal/Termination Form.  
All research staff responsible for obtaining consent will be trained and certified in the protection of 
human subjects and the study-specific consent procedures. A model written informed consent form, 
developed according to the requirements of the U.S. Office of Research Protections (OHRP), is found in 
appendix 2. Each site may modify the model consent to conform to local standards, but the OHRP 
required elements must be maintained. The research sites will also be responsible for translating the 
consent form into the appropriate language(s) for their local context. 
Global Network countries with legislation regarding the need to videotape consents will comply with the 
country regulations; however, this is not part of the consent form requirements. This will not be 
required by protocol but rather decided by each site so as to comply with local rules and regulations. 
2.4.4 
Masking 
Both the azithromycin and placebo will be procured from the same manufacturer. The packaging will be 
standardized across sites and will be labeled as: “Azithromycin 2 g or Placebo”, with the expiration data 
and a unique identifier. A certificate of authenticity will likewise be provided. 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
20 
Clinical and research staff as well as the women will be masked to treatment status unless there is a 
serious adverse event potentially related to the treatment modality that requires unmasking for safety 
reasons. There will be one pharmacist at each site who will monitor randomization, drug supply, and 
safety. Under the instruction of the DCC, the study pharmacist will be trained and authorized to apply 
un-masking procedures, if concerns about randomization or participant safety are identified. 
2.4.5 
Randomization Procedures 
Randomization of participants will be carried out to obtain a 1:1 allocation ratio between the treatment 
and placebo arms. Randomization will be stratified by site. A computer algorithm generated by the data 
coordinating center (DCC) will create the random assignment to one of the treatment arms based on 
randomly permuted block design with randomly varied block sizes. The block sizes will be known only by 
the DCC personnel.  Each site will receive a lot of the study drug to be distributed sequentially at the 
participating health facilities which are randomizing women for the study site. 
2.4.6 
Monitoring before Discharge 
Routine post-delivery care will be provided to participants by their clinical providers who will be masked 
to the study interventions. Research staff (also masked to study medications) trained in obstetric and 
perinatal outcomes abstraction will be responsible for collecting research data from participant medical 
records or directly from participants, as relevant, before discharge. Data needed to determine sepsis will 
include temperature (fever or hypothermia) essentially, plus one or more of heart rate (tachycardia), 
blood pressure (hypotension), respiratory rate (tachypnea or distress), clinical exam (jaundice or altered 
mental status) and urine output (low) and a suspicion of infection by the clinical provider or research 
team.  Maternal and neonatal outcomes will be evaluated in the hospital following the delivery (on an 
ongoing basis until discharge). All participants will be asked to agree to maternal/infant medical record 
release to abstract information for outcome assessment as part of the consent form. In addition, 
participants will be educated about the signs and symptoms of infection and other study outcomes and 
encouraged to call the research team with any concerns.  
2.4.7 
Monitoring after Discharge 
After discharge, study staff will contact participants at the following timepoints: 
• 
In-person visits will be conducted at 3-day, 7-day, and 42-day postpartum to identify maternal 
or infant infection, unexpected medical visits, side effects, and other study outcomes. WHO 
criteria for infections will be used and included in the data collection forms. In the case of 
suspected infection, research staff will collect specimens (e.g. blood, urine, or pus from wound 
or drained abscesses), as is feasible, in order to identify individual infectious agents. 
• 
Supplemental phone contacts will be conducted at 14-day and 28-day postpartum to review 
maternal and neonatal signs of infection using WHO criteria. If signs of infection are identified 
during the review, participants will be asked to visit a study facility for further assessment. These 
supplemental contacts will reinforce the participants’ ability to self-assess for signs of maternal 
and neonatal infection and improve identification of infection between the 7-day and 42-day 
postpartum visits. If phone contact is not feasible, in-person visits may be conducted. 
If indicated, records of unscheduled visits to any health facility prior to the routine study visits will be 
obtained and reviewed to ascertain study outcomes. Treating providers may also be called if clarification 
is needed. Based on the scheduled visits, study staff will identify any unscheduled visits or readmissions 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
21 
that occurred in the interim. Readmissions and related diagnoses identified during follow-up visits will 
be then be validated through medical record review. 
2.4.8 
Sequence of Study Activities 
The sequence of study activities is described in Figure 1. A detailed scheduled of study procedures is 
found in Appendix 3.  
Figure 1. Flowchart of Study Activities 
Maternal and Neonatal Monitoring
Maternal and Neonatal Monitoring
Final Outcome Assessment 
(42-day postpartum)
Informed Consent
Consented*
STOP
Randomize
Refused
Ineligible
Eligible
Labor and Delivery Outcome 
(Daily before discharge)
Refer for 
clinical assessment 
and culture 
Community Sensitization
Screening
Early consent 
(site dependent)
Azithromycin Administration
Treatment 
Arm
Control
Arm
*If early consent, confirmation of eligibility and reconfirmation of consent required.
In-person Visits 
(3, 7, and 42-day postpartum)
Supplemental Infection Contact
(14 and 28-day postpartum)
Placebo Administration
Labor and Delivery Outcome 
(Daily before discharge)
In-person Visits 
(3, 7, and 42-day postpartum)
Supplemental Infection Contact
(14 and 28-day postpartum)
Refer for 
clinical assessment 
and culture 
Suspected
Infection
Final Outcome Assessment 
(42-day postpartum)
Suspected 
Infection
 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
22 
2.5 
Primary Outcomes 
The primary outcomes are:  
• 
Maternal: Incidence of maternal death or sepsis within 6 weeks (42 days) post-delivery in 
intervention vs. placebo group. 
• 
Neonatal: Incidence of intrapartum/neonatal death or sepsis within 4 weeks (28 days) post-
delivery in intervention vs. placebo group. 
Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from suspected or 
confirmed infection that occurs post-randomization during labor or the postpartum period. This WHO 
definition, endorsed by multiple global health organizations, will be operationalized as suspected or 
confirmed infection based on the presence of fever (>100.4° F/38° C) or hypothermia (<96.8° F/36° C) 
plus one or more signs of mild to moderate organ dysfunction including tachycardia (≥120 bpm), low BP 
(systolic <90 mm Hg), tachypnea (>24 breaths/min), altered mental status/confusion, reduced urinary 
output (<500 ml over 24 hours), jaundice, or renal failure (>1.2 mg/dl). 15,40,41,42 Components of 
peripartum infection which will be considered in making the diagnosis of suspected or confirmed 
infection include clinical chorioamnionitis, endometritis, wound infections (perineal or Cesarean), 
abdominal or pelvic abscess, mastitis/breast abscess or infection, pyelonephritis, pneumonia, and other 
bacterial infection as defined in Section 2.6 below. 
Neonatal sepsis is defined as a newborn with proven or possible serious bacterial infection (pSBI) or 
pneumonia, or meningitis. Possible serious bacterial infection will be determined using WHO criteria of 
pSBI defined as severe chest in-drawing, fever (temperature ≥ 100.4° F/38.0 °C), hypothermia 
(temperature <95.9°F/35.5 °C), no movement at all or movement only on stimulation, feeding poorly or 
not feeding at all, and/or convulsions.33 Clinical and laboratory signs of infection will also be considered 
in making the diagnosis of suspected or confirmed infection. 
Centralized masked adjudication of key infection outcomes will be implemented by the DCC and investigators 
during the trial to standardize and enhance the reproducibility of trial results. In addition to the above 
specified criteria, reported antibiotic treatment and culture status will also be considered as part of the 
adjudication process in making the diagnoses for both maternal and neonatal sepsis.  Local site 
investigators will review and validate the diagnosis for all participants identified to have the primary 
outcomes applying pre-specified criteria. These reviews will be conducted masked to treatment group. A 
second investigator from a different site will review the participant’s information and make a final 
outcome determination. If this does not agree with the determination of the local site investigator, then 
the adjudicating investigator will discuss with the local investigator to reach a consensus, failing which 
the study PIs will make the final call. This process will be coordinated by the DCC. 
The individual components of these primary outcomes are also of interest and will be analyzed.  
2.6 
Other Maternal Outcomes 
a. Chorioamnionitis: Fever (>100.4°F/38°C) in addition to one or more of the following: fetal 
tachycardia ≥160 bpm, maternal tachycardia >100 bpm, tender uterus between contractions, or 
purulent/foul smelling discharge from uterus prior to delivery. 
b. Endometritis: Fever (>100.4°F/38°C) in addition to one or more of maternal tachycardia >100 bpm, 
tender uterine fundus, or purulent/foul smelling discharge from uterus after delivery.  

 
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23 
c. Other infections: Wound infection refers to purulent infection (superficial or deep infection 
including necrotizing fasciitis) of a perineal or Cesarean wound with or without fever. In the 
absence of purulence, a wound infection requires presence of fever (>100.4°F/38°C) and at least 
one of the following signs of local infection: pain or tenderness, swelling, heat, or redness 
around the incision/laceration; abdominopelvic abscess is evidence of pus in the abdomen or 
pelvis noted during open surgery, interventional aspiration or imaging; pneumonia refers to 
fever (>100.4°F/38°C) and clinical symptoms suggestive of lung infection including cough and/or 
tachypnea (>24 breaths/min) or radiological confirmation; pyelonephritis refers to fever 
(>100.4°F/38°C) and one or more of the following: urinalysis/dip suggestive of infection, 
costovertebral angle tenderness, or confirmatory urine culture; Mastitis/breast abscess or 
infection refers to fever (>100.4°F/38°C) and one or more of the following: breast pain, swelling, 
warmth, redness, or purulent drainage. 
d. Use of subsequent maternal antibiotic therapy after randomization to 42 days postpartum for 
any reason. 
e. Time from drug administration until initial discharge after delivery (time may vary by site). 
f. Maternal readmission within 42 days of delivery. 
g. Maternal admission to special care units. 
h. Maternal unscheduled visit for care. 
i. 
Maternal GI symptoms including nausea, vomiting, and diarrhea and other reported side effects. 
j. 
Maternal death due to sepsis using the Global Network algorithm for cause of death. 
2.7 
Other Neonatal Outcomes 
a. Other neonatal infections (e.g., eye infection, skin infection, omphalitis, urinary tract infection, 
respiratory rate ≥60 breaths/minute). 
b. Neonatal initial hospital length of stay, defined as time of delivery until initial discharge (time 
may vary by site). 
c. Neonatal readmission within 42 days of delivery. 
d. Neonatal admission to special care units. 
e. Neonatal unscheduled visit for care. 
f. Neonatal death due to sepsis using the Global Network algorithm for causes of death. 
g. Pyloric stenosis within 42 days of delivery, defined as clinical suspicion based on severe vomiting 
leading to death, surgical intervention (pyloromyotomy) as verified from medical records, or 
radiological confirmation.  
2.8 
Safety Monitoring 
Surveillance of maternal side effects including nausea, vomiting, and diarrhea/loose stools, abdominal 
pain, vaginitis, and dizziness potentially associated with azithromycin will be conducted during labor and 
postpartum. For infants, findings suggestive of pyloric stenosis will be assessed during the follow up 
visits. Maternal and neonatal surveillance will also include assessment of unintended medical visits, 
maternal deaths, stillbirths, neonatal death within 28 days of birth, and infant death after 28 days of 
birth. Additional maternal and neonatal risks associated with azithromycin use include anaphylaxis, 
allergic reactions (rash), liver failure, and arrhythmias. Although rare, these side effects will be 
monitored and reported as a serious adverse event. All safety outcomes will be reviewed at least twice a 
year by the Data Monitoring Committee (DMC) appointed by NICHD. 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
24 
2.9 
Site Preparation 
In preparation for study implementation, the site investigators will meet with local health authorities 
and conduct community sensitization activities to ensure that study procedures are appropriate for the 
local context and to encourage commitment and engagement at the facility and community level. Site 
preparation activities will focus on: 
• 
Disseminating study objectives to local health authorities and other stakeholders 
• 
Identifying and hiring study staff; 
• 
Developing site-specific procedures for safety monitoring procedures; 
• 
Exploring locally-acceptable methods to monitor and improve follow-up visit compliance; 
• 
Identifying potential implementation challenges and developing culturally-appropriate solutions; 
• 
Training research staff in the implementation of the study procedures, follow-up and ascertainment 
of infections. 
2.10 Potential Risks and Benefits to Participants 
There are several potential direct and indirect benefits of this trial. In developing countries, including 
those of GN partners, fetal and neonatal deaths due to infections and maternal and neonatal infections 
are common. If intrapartum azithromycin reduces maternal and fetal/neonatal mortality or infections, 
many deaths could be reduced in the GN sites as well as worldwide.  
Emerging data suggest that intrapartum azithromycin reduces maternal and neonatal infection. It is not 
known if deaths could be prevented but as infections are one of the most frequent causes of maternal 
and neonatal deaths, there is a possibility that mortality could be reduced.  
An ongoing concern for peripartum and perinatal antibiotic prophylaxis is the selection of resistant 
organisms including azithromycin-resistant organisms leading to resistant infections, and there is 
concern that disruption of gut and other flora (microbiome) in women and particularly in neonates may 
lead adverse events including increased allergic reactions, rash and childhood asthma.12,18,40 In the trial 
from Gambia of a single oral dose of azithromycin during labor, higher prevalence of colonization with S. 
aureus azithromycin resistance observed among women and their babies four weeks after treatment 
had waned 12 months later and azithromycin did not induce other antibiotic resistance to S. 
pneumoniae or S. aureus; resistance data from actual infections were not available. There was a 7% vs. 
21% prevalence of any bacteria in breast milk in those receiving azithromycin vs. placebo [4-5]. In the US 
trial of 2013 of adjunctive azithromycin in 2013 women who underwent unscheduled cesarean delivery, 
culture positive maternal infections (1.4% vs. 3.6%) and infections with at least one resistant bacterial 
species (1% vs. 2.4%) were significantly less frequent in the azithromycin group. Azithromycin-resistant 
organisms were identified in only 7 (3 vs. 4) participants. There is a paucity of data to address theoretical 
concerns that disturbances in the establishment of the indigenous intestinal microbiome caused by 
antibiotic exposure in early life or cesarean delivery, either directly or through modifications of breast 
microbiome, may increase risk of immune-mediated and inflammatory conditions such as atopic 
disorders, inflammatory bowel disease and obesity later in life.27-30 While the potential for important 
benefits in both the mother and infant likely outweighs the likelihood and effects of antibiotic resistance 
and microbiome changes, these  should be monitored. In addition to monitoring resistance patterns in 
isolates from clinical infections, antimicrobial and microbiome surveillance of a subset of enrolled 
participants are included in an ancillary protocol. 

 
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25 
3 ANALYTICAL PLAN 
Baseline demographic characteristics and key clinical measures will be compared between the women in 
the two treatment arms using contingency table approaches for categorical variables and analysis of 
variance models’ continuous variables.  
For summaries of study data, categorical measures will be summarized in tables listing the frequency 
and the percentage of participants; continuous data will be summarized by presenting mean, standard 
deviation, median and range; and ordinal data will be summarized by only presenting median and range. 
P-values presented will be based on two-sided tests unless otherwise specified and generally adjusted 
for randomization factor of site. For most analyses, the interaction between treatment and site will be 
assessed and if significant, results will also be presented by site. For continuous outcomes, distributional 
properties will be evaluated and if required, transformations or non-parametric tests will be employed. 
Additional details for potential covariate adjustments in secondary analyses or handling violations of 
analytic method assumptions will be detailed in the statistical analysis plan. 
Three key populations are of interest for study analyses:  
1. The Intention to Treat (ITT) population will include all women randomized and their infants. 
Analyses of this cohort will be conducted based on randomized treatment. 
2. The High-Risk for Infection (HR) sub-group will include all women in the ITT and their infants 
meeting criteria for being high risk (i.e., prolonged labor [≥18 hours] and/or rupture of 
membranes [≥8 hours]) at the time of randomization. Analyses of this cohort will be conducted 
based on randomized treatment. 
3. The As Treated population will include all randomized participants that receive any study drug during 
the study and their infants. Analyses of this cohort will be conducted based on treatment received. 
 
The final determination of analysis population membership will be via a masked data review prior to final 
study analyses in order to address any potential anomalous cases that may arise in this large of a study 
population (e.g., randomization/treatment of a woman who is discharged prior to delivery due to false labor 
or unresponsiveness to induction). 
3.1 
Statistical Analysis Plan 
3.1.1 
Primary Analyses 
Incidence of maternal death or sepsis and intrapartum/neonatal death or sepsis will be compared 
between the two treatment arms using generalized linear models. These generalized linear models will 
be fit with each binary outcome separately as the outcome measure. Estimates of relative risk and 
associated 95% confidence intervals will be reported. The model will include terms for treatment and 
site. As randomization occurs at the pregnancy level and approximately 1-2% of pregnancies are 
anticipated to be multiple gestations, models for neonatal outcomes will account for correlation among 
multiples assuming an exchangeable covariance structure. For the two primary outcomes, these 
analyses will be conducted using the ITT population and the p-values associated with the treatment 
term will be used to formally test each of the two primary hypotheses at the alpha = 0.05 level.  
As secondary analyses of the primary outcomes, assuming an overall treatment effect is observed, the 
models will be run including region (Africa, Latin America, or Asia) and a treatment by region interaction 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
26 
term. If the interaction term has a p<0.1, then effects will be reported by region with treatment effect 
within region tested at the 0.025 level.  
Additional exploratory models will also be run including individually: 1) a treatment by site interaction 
term, 2) any other antibiotic use during labor (yes or no) and its interaction with treatment, and 3) mode 
of delivery (cesarean or vaginal) and its interaction with treatment.  If the interaction term for any of 
these models has a p<0.1, then effects will also be reported by the relevant subgroups. These 
exploratory secondary models will also include any demographic or clinical variables found to differ 
significantly between the treatment arms in the preliminary analyses described above.   
From each final model, estimates of relative risk associated with treatment will be obtained including 
unadjusted estimates of risk from the primary model as well as estimates of risk adjusted for potential 
confounders from the secondary analyses. 
3.1.2 
Secondary Analyses – Women at High Risk for Infection Cohort  
The major secondary aim is assessing the two primary outcomes (i.e., incidence of maternal death or 
sepsis and incidence of intrapartum/neonatal death or sepsis) in the women at high risk for infection 
cohort. These analyses will also assess if the treatment effect differs between the HR cohort vs. non-
high-risk women where non-high-risk women comprise all women and their infants in the ITT population 
that delivered prior to meeting criteria for high-risk (i.e. they delivered after < 18 hours of labor and < 8 
hours post-rupture of membranes relative to time of randomization). Specifically, the model for the 
primary analysis of both the maternal and neonatal primary outcomes will be run including a treatment 
by risk status interaction term and excluding any data from individuals that meet high-risk criteria after 
randomization.  
The exclusion of data from individuals meeting high risk criteria between randomization and delivery is 
intended to provide the most distinct groups regarding the HR risk cohort to non-high-risk women 
comparison. As this exclusion is based on a post-randomization event, sensitivity analyses will be 
conducted to examine any treatment group differences in meeting high risk criteria post randomization 
and if there is a difference, to determine the potential magnitude of impact this difference has on 
treatment effect.  An exploratory analysis will also be completed that assesses if there is a difference in 
treatment effect between women randomized prior to high-risk classification vs. those randomized after 
high-risk classification. Finally, an exploratory analysis will be conducted that assesses the definition of 
high-risk to determine if there is a different cut-off that identifies a group of individuals with a greater 
treatment effect both in relation to randomization and delivery. 
3.1.3 
Secondary Analyses – Other Secondary Outcomes 
Other maternal and neonatal binary outcomes including: the individual components of the primary 
outcomes, neonatal deaths due to sepsis, maternal infections (clinical chorioamnionitis, endometritis, 
wound infections (perineal or subsequent cesarean), pyelonephritis and pneumonia), use of subsequent 
maternal antibiotic therapy, pyloric stenosis and occurrences of maternal or neonatal readmission or 
admission into special care unit will be analyzed using the approaches detailed in Section 3.1.1 for the 
ITT population and approaches detailed in Section 3.1.2 for the HR cohort. A similar process with 
generalized linear models employing an appropriate link function will be used to analyze the outcomes 
of maternal and neonatal initial hospital length of stay. 

 
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27 
Binary safety outcomes, e.g., nausea, vomiting, and diarrhea, will also be analyzed using the approaches 
detailed in Section 3.1.1. These analyses will be conducted using the As Treated population.  
3.2 
Sample Size 
3.2.1 
Sample Size for Primary Outcome 
Sample size estimates were generated to evaluate the potential benefits of peripartum prophylactic 
azithromycin to reduce the risk of adverse maternal and neonatal outcomes in two population cohorts 
of women in low and low-middle income settings. The first population of interest comprises all women 
delivering in facilities (overall).  
Power calculations for the study in the overall study population were generated for two primary 
outcome measures, one being the risk of maternal death or sepsis among women in the target 
population and the other being intrapartum /neonatal death or sepsis in infants delivered by women in 
the target population. For each of these outcome measures estimates of the required sample size 
needed to detect a risk reduction of 20%, 25%, and 30% were generated for power of 0.8, 0.85, and 0.9. 
The risk of sepsis or maternal death was assumed to be 3%. That number is slightly higher than the 
current risk in the GN population, which is slightly less than 2%. However, we anticipate that with active 
surveillance rather than passive reporting based on the new WHO definition of maternal sepsis 
(designed to catch more cases of sepsis), the risk will be at least 3%. For the neonatal outcome, the 
underlying risk of the combined outcome of intrapartum stillbirth, neonatal death, or sepsis was 
assumed to be between approximately 8% and 14%. This estimate was based on recent data from the 
GN indicating that the risk of intrapartum stillbirth is approximately 1.8% and the risk of neonatal death 
during the first 28 days after delivery is 2.3%; we assumed that the risk of sepsis not resulting in death is 
approximately 4% to 10%. The resulting required evaluable sample sizes are shown in Table 1 below. 
 
Table 1. Sample Sizes for the Overall Population, Alpha=0.05 
 
 
Evaluable Sample Size per Arm 
Baseline Risk 
Risk Reduction 
Power=0.80 
Power=0.85 
Power=0.90 
3% 
20% 
11455 
13103 
15334 
3% 
25% 
7133 
8159 
9548 
3% 
30% 
4815 
5508 
6446 
8% 
20% 
4096 
4686 
5483 
8% 
25% 
2554 
2921 
3419 
8% 
30% 
1727 
1975 
2311 
14% 
20% 
2204 
2521 
2950 
14% 
25% 
1377 
1575 
1842 
14% 
30% 
932 
1066 
1247 
The sample sizes shown above assume that the hypothesis test of interest is for the overall population 
and that the Type 1 error is controlled at the neonatal and maternal hypothesis level via testing each at 
an alpha = 0.05 level. Interest has been expressed for the overall study for being able to test the 
neonatal risk separately in south Asia and sub-Saharan Africa. Controlling the Type I error rate at the 
0.025 level for each of those two areas within this sub-analysis of neonatal risk will be conducted to 
avoid multiple comparison concerns. The resulting sample sizes for that comparison are shown in Table 
2 below. Note that this sample size would be the size required separately for the African and Asian sites. 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
28 
It is planned that each site will enroll approximately equal number of participants.  As such, 
approximately 37.5% of randomized mothers will be from sub-Saharan Africa and 50% will be from Asia.  
This planned enrollment distribution is approximately equivalent to the rates of in-facility deliveries 
observed in the GN registry database. Specifically, approximately a third of the facility deliveries are 
conducted in sub-Saharan Africa and between 45% and 50% of the facility deliveries are conducted in 
Asia. These estimates are also consistent with the enrollment rates for the ASPIRIN study that is 
currently being conducted at these sites. Therefore, to get the total study sample size required, the 
numbers in the table would need to be multiplied by 3 to achieve reasonable power for the African sites. 
Table 2. Sample Sizes Within Region, Alpha=0.025 
 
 
Evaluable Sample Size per Arm 
Baseline risk 
Risk Reduction 
Power=0.80 
Power=0.85 
Power=0.90 
8% 
20% 
4961 
5607 
6477 
8% 
25% 
3093 
3496 
4038 
8% 
30% 
2091 
2363 
2729 
14% 
20% 
2669 
3017 
3485 
14% 
25% 
1677 
1884 
2176 
14% 
30% 
1129 
1276 
1474 
 
Given the above information, we propose a sample size of 34,000 participants for the overall study. For 
the primary neonatal outcome of interest of intrapartum/neonatal sepsis or death, assuming that the 
loss to follow-up will be in the 2% to 3% range (consistent with the current ASPIRIN trial and the Global 
Network Maternal and Newborn Health registry), this sample size will be sufficient to provide 90% 
power to detect a 25% reduction in neonatal mortality and sepsis in the sub-Saharan African region and 
will provide 90% power to detect a 20% reduction in Asia assuming the baseline risk is at least 8%. For 
the primary maternal outcome of maternal death or sepsis, the sample size will provide 90% power to 
detect a 20% reduction from 3% in the population aggregated across all study sites. 
3.2.2 
Sample Size for High-Risk Women 
The second population of interest comprises the cohort of high-risk population of women delivering in 
facilities with high risk being defined as term and preterm pregnant women who experience prolonged 
labor or prolonged membrane rupture. As a major secondary aim, sample size estimates for the high-
risk cohort were also obtained to ensure adequate power for this analysis.  
The primary objective of the high-risk component of the study is to test the effectiveness of a single oral 
dose of intrapartum azithromycin prophylaxis compared to placebo (all receive usual care) in reducing 
the risk of maternal sepsis or death in high-risk laboring women. To estimate the sample size required 
for this component of the study, we assumed conservatively that the underlying risk of the combined 
outcome in the target population is 6%. Comparable to the other study estimates of the required 
sample size needed to detect a risk reduction of 20%, 25%, and 30% were generated for power of 0.8, 
0.85, and 0.9. Because the interest for this study is in testing the hypothesis overall rather than by 
region, the estimates were generated using an alpha of 0.05. The results of these calculations are shown 
in Table 3 below. 
 
 

 
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29 
Table 3. Sample Sizes for the High-Risk Cohort, Alpha=0.05 
Baseline risk 
Risk Reduction 
Evaluable Sample Size per Arm 
 
 
Power=0.80 Power=0.85 Power=0.90 
6% 
20% 
5568 
6369 
7453 
6% 
25% 
3470 
3969 
4644 
6% 
30% 
2344 
2681 
3138 
Because a risk reduction of at least 30% is expected in this population, we propose a sample size for this 
HR cohort of 5,500 women. That sample size will be sufficient to detect a 30% risk reduction with a 
power of 0.85 with an assumed 2% to 3% loss to follow-up. Assuming that 20% of the women are at high 
risk, the overall study sample size of 34,000 should allow for sufficient enrollment into the HR cohort. 
If the proportion of “high-risk” women is smaller than anticipated, the target enrollment may be 
modified.  A smaller sample size should still provide sufficient power for plausible potential underlying 
scenarios.  For example, a sample size of approximately 4,000 high risk women will be sufficient to 
detect a 33% risk reduction with a power of 0.82 assuming a baseline risk of at least 6% as well as a 35% 
risk reduction with a power of 0.80 assuming a baseline risk of at least 5%. 
3.3 
Available Population 
There are no competing protocols ongoing in the GN. Assuming conservatively that 50% of women in 
labor (30,000 facility births per year) meet eligibility criteria for entry and are enrolled in the trial, 
approximately 15,000 women/infant dyad will be enrolled per year.  
To reach the enrollment target of 34,000, each study site will aim to recruit an equal number of study 
participants (n=4,250 per site); however, recruitment will be monitored and if a site does not meet 
targets, adjustments may be made.  No site will be permitted to recruit more than 20% of the overall 
study sample site.   
Based on historic GN data, we anticipate that the target of 5,500 high-risk women will be enrolled during 
the trial. However, through ongoing monitoring, the DCC will assess the number of women enrolled in 
the “high-risk” group and may modify target enrollment as needed to ensure at least 5,500 high-risk 
women are enrolled. 
3.4 
Projected Recruitment Time 
The projected study timeline is 36 months or less. This includes the following: 
• 
0-6 months: Finalize protocol, forms. Obtain approvals, train staff, and obtain/ship study 
drug/placebo to sites. 
• 
7-31 months: Enroll participants (exact period of enrollment may vary by site) 
• 
32-36 months: Complete follow-up; data cleaning and primary analyses. 
3.5 
Study Monitoring Plan 
3.5.1 
Reporting Serious Adverse Events 
Serious Adverse events (SAEs) will be monitored continuously for any event that meets the following 
criteria: 
• 
Results in neonatal/fetal or maternal death; 
• 
Is life-threatening; 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
30 
• 
Requires hospitalization or prolongs existing hospitalization; 
• 
Results in persistent or significant disability or incapacity; 
• 
Suspicion of pyloric stenosis within 42 days postpartum (prolonged vomiting leading to death or 
surgery) 
• 
Any other serious or unexpected adverse event that the study investigator(s) feels should be 
reported. 
3.5.2 
Method and Timing for Reporting Serious Adverse Events 
The Senior Foreign Investigator (SFI) must report the following SAEs by emailing or faxing a copy of the 
appropriate study form to RTI as follows: 
Within 48 hours of SFI’s notification of the event: 
• 
All deaths (maternal, intrapartum stillbirths, neonatal)  
• 
All SAEs with a definite or suspected/probable relationship to the intervention 
Within 7 days of SFI’s notification of the event:  
• 
All life-threatening events; 
• 
All SAEs considered to have a probable or possible relationship to the intervention; 
• 
All emailed or faxed forms should also be entered into the DMS and transmitted within 7 days as 
a back-up to ensure no SAE is missed.  
Additional reporting procedures include: 
• 
RTI will forward all SAEs to the US-based Principal Investigator (PI) and NIH for further 
assessment of relationship to study intervention. The PI and SFI will be responsible for reporting 
to their respective IRB and other regulatory authorities per their institutional policy.  
• 
RTI will be responsible for reporting SAEs to the DMC bi-annually at a minimum. The frequency 
of reporting to the DMC may be increased if the reported events or interim data reviews by the 
DMC indicate that more frequent safety monitoring is needed. 
• 
Any SAE considered unrelated to the intervention is not required to be reported in an expedited 
manner. These events should be entered into the data management system and transmitted per routine 
procedures.  
3.5.3 
Data Monitoring Plan and Stopping Rules 
All the Global Network sites will report data to the Global Network Data Coordinating Center, located at 
RTI International. The data will be used to evaluate protocol adherence and site performance (e.g., 
recruitment, loss to follow-up, data quality). The DCC will provide standardized progress reports to 
NICHD and the site investigators on a monthly basis to monitor outcome variables and adverse events. 
Oversight of the trial will be handled by two principal groups with different focuses: 
1. Protocol-focused Steering Committee (SC): The SC is comprised of the Central Study Team from the 
University of Alabama at Birmingham and the University of Zambia, NICHD, the DCC, and 
investigators from each of the participating sites (see Azithromycin Investigators on page 8). The 
Central Study Team, with assistance from NICHD and the DCC, will have primary responsibility for 
overall study design, development of study materials and procedures, and oversight of study 
implementation. They will meet via conference call bi-weekly to monitor study progress and ensure 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
31 
proper implementation of the trial. The Site Investigators will be responsible for providing guidance 
on study design, developing site-specific implementation plans, ensuring study staff are properly 
trained, and providing oversight of the study at the site level. The SC will convene via conference call 
at least once per quarter and will meet in person twice a year to discuss study design and 
implementation issues. Members of the Central Study team, NICHD, and RTI will also conduct site 
visits, as the budget allows, to bolster enthusiasm, provide hands-on training and education to the 
participating staff, and address site-specific issues, if any. 
2. Data Monitoring Committee (DMC): The DMC, a standing group that monitors all NICHD-funded 
Global Network studies, will be responsible for ensuring safe and ethical treatment of study 
participants through monitoring of the study. The membership will include, at a minimum, a 
statistician, obstetrician, pediatrician, and an expert in international health. The DMC designated by 
NICHD will review the data collected at approximate 6-month intervals throughout the course of the 
study. The DMC reports, which are prepared by the Data coordinating center, will include 
information on study enrollment rates and participant progress through the study, participant 
compliance with protocol-specified treatment regimens, protocol violations, adverse events, and 
efficacy outcomes. The focus of the DMC review will be on monitoring participant safety and study 
progress/futility. Data on treatment effectiveness will also be presented to frame the DMC 
discussions on safety and futility. Additionally, one formal interim analyses of efficacy is planned as 
detailed in Section 3.5.4. The DMC will be charged with monitoring adverse events and side effects 
from azithromycin. All known associated side effects and specific obstetric, fetal, or neonatal 
concerns will be considered reportable to the DMC. The study will be reviewed by the DMC bi-
annually at a minimum but may be reviewed more frequently if concerns are raised about 
participant safety or about adequate process of the study. 
3.5.4 
Interim/Adverse Event Monitoring Plan  
The DMC designated by NICHD will complete safety reviews of the data bi-annually at minimum during 
the intervention phase or as often as they decide. Safety reports will be reviewed internally by the DCC 
quarterly and the DMC chair will be notified if any potential safety signals are identified to allow for 
more frequent DMC monitoring if needed.  Adverse events will the reported and submitted to the DCC 
(and IRBs) who will report these cumulative masked data to the DMC in the safety reviews. The DMC 
recommendations about study continuation will be distributed to the IRBs. The DMC will forward their 
monitoring activities to the project officer representing the NICHD. 
Additionally, one formal interim analysis of efficacy and futility will be conducted during the study. 
Interim analyses will be conducted in both all-comers and high-risk cohort assessing both the primary 
maternal and neonatal outcomes use the primary analytic approach detailed in Section 3.1.1 and 3.1.2. 
As the maternal and neonatal hypotheses are both of equal importance as well as the treatment effect 
within the two cohorts, the DMC will not be able to recommend early termination for efficacy unless 
significance is observed for both outcomes in all comers and the direction and magnitude of effect in the 
high-risk cohort is consistent with the effect observed in all comers. Cut-off p-values for testing for 
efficacy at this interim analysis will be determined based on a correction for multiple comparisons to 
ensure an overall alpha of 0.05. The futility assessment will be based on an analysis of conditional 
power. The details of the timing of the interim analysis as well as the approaches for correcting for 
multiplicity and analyzing conditional power will be determined in collaboration with the DMC prior to 
initiation of study enrollment. Safety and efficacy of the azithromycin will be reviewed and compared 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
32 
with data from the placebo group according to a data center plan. The primary outcome rate will be 
calculated, and the data center will develop guidelines for interim analysis decision-making (e.g. the 
O’Brien-Fleming boundary table). 
3.5.5 
Risks/Benefits 
Based on the preliminary data, there are few risks to this intervention especially given the single oral 
dose. Severe risks include anaphylaxis and allergic reactions (rash) and liver failure which are rare with 
azithromycin based on the product insert and our long history of use of prophylactic azithromycin at 
UAB since 2000. In 2013, the FDA issued an advisory regarding concerns about potential for rare life-
threatening arrhythmias with azithromycin use particularly among those with preexisting cardiovascular 
risk. To minimize the risk of life-threatening side effects, those with arrythmia, known history of 
cardiomyopathy, or a known allergy to azithromycin will be excluded. With single 1-2 gram doses, 
gastrointestinal symptoms (nausea 5-18%, diarrhea/loose stools 7-14%, abdominal pain 5-7%, vomiting 
2-7%, and dyspepsia 1%) as well as vaginitis 2% and dizziness (1%) were the most commonly reported 
side effects. These side effects will be monitored.  
3.6 
Quality Control  
3.6.1 
Training 
All study personnel must participate in training on the proper implementation of study procedures and 
the ethics of conducting research with human subjects before beginning any research activity. The SFI 
and project coordinator will ensure that all study personnel receive the appropriate training and obtain 
the required certification. RTI will be responsible for developing a certification test. The SFI and project 
manager will be responsible for overseeing the certification process. 
3.6.2 
Study Monitoring 
Major monitoring responsibilities of the PI/SFI, assisted by the country coordinator, are (1) confirming 
proper IRB approval; (2) monitoring delivery of the study intervention; (3) assessing and evaluating 
quality of study implementation; (4) ensuring compliance with the intervention, including proper 
randomization; (5) evaluating accuracy, precision, and completeness of data collected, entered, and 
transmitted, along with the DCC; (6) ensuring that all personnel are fulfilling their obligations; (7) 
maintaining staff morale and enthusiasm; (8) maintaining communication and handling ad hoc 
problems; (9) ensuring inter-site consistency; and (10) proposing improvements to monitoring activities. 
NICHD and the DCC staff will conduct site visits as needed. These visits will include review of individual 
participant records, including supporting data, to ensure protection of study participants, compliance 
with the protocol, and accuracy and completeness of records. The SFI/PI will make study documents 
(e.g., logbooks, data forms, staff training certificates) and pertinent hospital/clinic records readily 
available for inspection by the local IRB, site monitors, and the NICHD for confirmation of the study data. 
3.6.3 
Drug Quality Assurance and Monitoring 
The study drug manufacturer will have a Good Manufacturing Practices designation vetted by the FDA 
and a certificate of authenticity will be provided. Each site will adapt best practice guidelines for drug 
shipment and storage to the needs and infrastructure of their local environment. Study staff will be 
trained in on the drug shipment and storage plan to ensure that best practices are maintained at all 
times. Additionally, participants will receive detailed instruction on proper storage of the study drug at 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
33 
home. Drug stability information will be maintained throughout the study. For quality assurance, a 
sample of pills from each site will be randomly selected and tested for bioavailability at multiple time 
points during the study period. A sample from each batch will be tested.  
3.6.4 
Plan for Sustaining Intervention 
We will plan to present abstracts to reputable international obstetric meetings (e.g. SMFM, ACOG or 
FIGO) and manuscripts within 3-6 months of completion of the primary data collection to high impact 
journals such as the New England Journal of Medicine, JAMA, or the Lancet. If the results are positive, 
we will facilitate the change in practice at participating sites and also approach the WHO to instigate 
guideline updates to reflect the study findings. 
4 DATA MANAGEMENT PROCEDURES 
Data will be collected both prospectively and from existing medical records, using hard copy forms or 
Android Tablets. Regardless of data capture methodology, all data will be kept confidential. Each 
participant will be assigned a unique study ID which will be used to identify the participant. Only the 
screening log will contain the name (which is not transmitted). If hard copy forms are used, they will be 
retained in a secure location for possible editing or queries at the central data entry site. Data will be 
entered into computers using the Data Management System (DMS) developed by RTI and the assigned 
study number. The DMS will also allow site staff to produce project reports and backup the study 
database. Electronic data will be transferred from each data management computer to a single Research 
Unit Data Center in each country, creating a complete data repository. At least once a week, data will be 
transmitted from the Research Unit Data Center to the DCC at RTI, where the central database will be 
located. The DCC will conduct training on data collection procedures and the DMS system, as needed.  
Precision and accuracy of actual data collected will be checked by chart review (random 5%) and internal 
procedures using the computer program. Monthly audits and incomplete data reports will be performed 
by a review team consisting of at least the SFI and country coordinator. Data editing and error resolution 
will be performed monthly. In addition, a sample of participants will be visited to confirm participation, 
with procedures determined per site. These activities will be shared between the site and the DCC. The 
timing of data collection is found in the schedule of study procedures (Appendix 3). 
4.1 
Data Forms 
The following forms will be used for this study: 
Form Name 
Purpose 
Key Data Elements 
Data Source 
Contact and 
Scheduling Form 
To facilitate participant 
follow-up by 
documenting contact 
information and 
projected study visit 
schedule  
Contact information, date of enrollment, date of follow-
up visits 
Participant interview, study 
calendar  
Screening and 
Enrollment Form 
To determine eligibility 
and record consent 
status 
Screening date, review and confirmation of 
inclusion/exclusion criteria, consent status/date. 
Participant interview/report, 
clinical assessment, provider 
report, medical records 
Randomization 
Form 
To confirm eligibility 
and track randomization 
Eligibility confirmation, randomization date/time, drug 
administration date/time, any problems with drug 
administration (e.g., vomiting, dropped med, etc).  
Study records, participant 
interview and observation 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
34 
Form Name 
Purpose 
Key Data Elements 
Data Source 
Maternal Baseline 
Data Form 
To collect additional 
maternal information  
• 
Demographic and baseline clinical data: admission 
date/time, EDD, GA, age, height, weight, pregnancy 
and medical history, etc. 
• 
Events during labor and delivery: timing of onset of 
labor, prolonged labor, premature rupture of 
membranes, date/time/type of membrane rupture, 
date/time/type of delivery, indication for induction 
(if applicable), vital signs during labor (temp, HR, 
RR, BP), complications, etc. 
• 
Events after delivery: complications, vital signs, etc. 
• 
Infection assessment pre- and post-delivery 
• 
Antibiotic treatment pre- and post-delivery 
• 
Discharge information 
Participant interview/report, 
provider report, medical 
records 
Neonatal Baseline 
Data Form 
To collect information 
about the infant directly 
after delivery. 
• 
Sex 
• 
Birthweight 
• 
Delivery outcome (live or stillbirth) 
• 
Complications 
• 
Infection assessment  
• 
Discharge information: date/time, status 
(discharged, transferred, died) 
Participant interview/report, 
provider report, medical 
records 
Maternal and 
Neonatal Follow-
up Form 
To collect maternal and 
infant health status 
during follow-up visits 
at 3 days, 7 days and 42 
days  after delivery. 
• 
Timing follow-up 
• 
Maternal and infant status since discharge: general 
status, symptoms, indication of infection, clinic 
visits, hospitalizations, antibiotic use  
• 
Temperature 
In-person participant 
interview/report and clinical 
exam 
Supplemental 
Infection Contact 
Form 
To document signs of 
maternal or neonatal 
infection and provide 
referrals if indicated. 
• 
Maternal and neonatal infection danger signs. 
• 
Referral information. 
Participant interview/report 
by phone 
Maternal and 
Neonatal 
Unscheduled 
Medical Visit 
To collect information 
about clinical events 
reported during follow-
up visits 
Reason for medical visit, details about medical visit 
Participant interview/report, 
provider report, clinical exam, 
medical records 
Specimen 
Collection and 
Result Form 
To track specimen 
collection when there is 
indication of maternal 
or infant infection 
Date/time of specimen collection; reason for collection; 
location of wound/infection; tracking information for 
shipping/storing specimen; results  
Study documentation if 
collected and/or tested by 
study; medical records if 
collected and/or tested by 
health facility. 
Serious Adverse 
Events 
To record fatal, life-
threatening, or any 
other serious, 
unexpected adverse 
event 
Date/time of event, date/time of resolution, nature of 
adverse event, management of adverse event, 
attribution to study (yes/no). 
Participant interview/report, 
provider report, medical 
records 
Final Study Status 
To document final study 
status  
Final study status (e.g., completion, withdrawal, lost-to-
follow-up), Date of final study status. If withdrawal, 
provide reason.   
Participant report, medical 
records 
Protocol Deviation  To record protocol 
deviations and 
corrective actions  
Date and nature of deviation/violation, corrective 
action. 
Participant report, study 
records, medical records 
Outcome 
Adjudication 
To validate cases of 
infection using standard 
study definitions 
Primary and secondary outcomes 
Study documentation, 
provider reports/interviews, 
medical records 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
35 
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World Health Organization. (2015). WHO recommendations for the prevention and treatment of maternal 
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Liu, L., Oza, S., Hogan, D., Perin, J., Rudan, I., Lawn, J. E., . . . Black, R. E. (2015). Global, regional, and 
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Baqui, A. H., Saha, S. K., Ahmed, A. S., Shahidullah, M., Quasem, I., Roth, D. E., . . . Projahnmo Study Group 
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Mackeen, A. D., Packard, R. E., Ota, E., Berghella, V., & Baxter, J. K. (2014). Timing of intravenous 
prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean 
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https://doi.org/10.1002/14651858.CD009516.pub2 
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Smaill, F. M., & Grivell, R. M. (2014). Antibiotic prophylaxis versus no prophylaxis for preventing infection 
after cesarean section. Cochrane Database of Systematic Reviews, 10, CD007482. 
https://doi.org/10.1002/14651858.CD007482.pub3 
11. 
Gyte, G. M. L., Dou, L. X., & Vazquez, J. C. (2014). Different classes of antibiotics given to women routinely 
for preventing infection at caesarean section. Cochrane Database of Systematic Reviews, 11(11). 
https://doi.org/10.1002/14651858.CD008726.pub2 
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Tita, A. T. N., Rouse, D. J., Blackwell, S., Saade, G. R., Spong, C. Y., & Andrews, W. W. (2009). Evolving 
concepts in antibiotic prophylaxis for cesarean delivery: a systematic review. Obstetrics and Gynecology, 
133(3), 675-682.  
13. 
Tita ATN, S. J., Boggess K, et al. . (2016). Adjunctive azithromycin prophylaxis for cesarean delivery. New 
England Journal of Medicine, 375, 1231-1241.  
14. 
Oluwalana, C., Camara, B., Bottomley, C., Goodier, S., Bojang, A., Kampmann, B., . . . Roca, A. (2017). 
Azithromycin in labor lowers clinical infections in mothers and newborns: a double-blind trial. Pediatrics, 
139(2). https://doi.org/10.1542/peds.2016-2281 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
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15. 
World Health Organization. (2017). Statement on maternal sepsis. Retrieved Ausust 22, 2018, from 
http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/maternalsepsis-
statement/en/ 
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Reinhart K, D. R., Kissoon N, Machado FR, Schachter RD, Finfer S.  . (2017). Recognizing sepsis as a global 
health priority - a WHO resolution. New England Journal of Medicine, 377(5), 414-417.  
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van Dillen, J., Zwart, J., Schutte, J., & van Roosmalen, J. (2010). Maternal sepsis: epidemiology, etiology 
and outcome. Current Opinion in Infectious Diseases, 23(3), 249-254. 
https://doi.org/10.1097/QCO.0b013e328339257c 
18. 
Roca A, O. C., Bojang A, Camara B, Kampmann B, Bailey R, Demba A, Bottomley C, D'Alessandro U. (2016). 
Oral azithromycin given during labour decreases bacterial carriage in the mothers and their offspring: a 
double-blind randomized trial. Clin Microbiol Infect. , 22(6), e1-9.  
19. 
Subramaniam A, Ye Y, Mbah R, Mbunwe DM, Pekwarake S, Bunwi EY, Fondzeyuf A, Ngong MG, Dionne-
Odom J, Harper LM, Jauk VC, Carlo WA, Halle-Ekane G, Szychowski JM, Tih P, Tita AT. Single Dose of Oral 
Azithromycin With or Without Amoxicillin to Prevent Peripartum Infection in Laboring, High-Risk Women 
in Cameroon: A Randomized Controlled Trial. Obstet Gynecol. 2021;138(5):703-713. PMID: 34619734. 
20. 
Harper, L. M., Kilgore, M., Szychowski, J. M., Andrews, W. W., & Tita, A. T. N. (2017). Economic evaluation 
of adjunctive azithromycin prophylaxis for cesarean delivery. Obstetrics and Gynecology, 130(2), 328-334. 
https://doi.org/10.1097/AOG.0000000000002129 
21. 
Andrews, W. W., Hauth, J. C., Cliver, S. P., Savage, K., & Goldenberg, R. L. (2003). Randomized clinical trial 
of extended spectrum antibiotic prophylaxis with coverage for Ureaplasma urealyticum to reduce post-
cesarean delivery endometritis. Obstetrics and Gynecology, 101(6), 1183-1189.  
22. 
Tita AT, H. J., Grimes A, Owen J, Stamm AM, Andrews WW.  . (2008). Decreasing incidence of post-
cesarean endometritis with extended-spectrum antibiotic prophylaxis. Obstetrics and Gynecology, 111(1), 
51-56.  
23. 
Tita, A. T., Owen, J., Stamm, A., Hauth, J. C., & Andrews, W. W. (2008). Impact of extended-spectrum 
antibiotic prophylaxis on incidence of post-cesarean surgical wound infection. American Journal of 
Obstetrics and Gynecology, 199(3), 303.  
24. 
Watts, D. H., Eschenbach, D. A., & Kenny, G. E. (1989). Early postpartum endometritis: the role of bacteria, 
genital mycoplasmas, and Chlamydia trachomatis. Obstetrics and Gynecology, 73(1), 52-60.  
25. 
Hoyme, U. B., Kiviat, N., & Eschenbach, D. A. (1986). Microbiology and treatment of late postpartum 
endometritis. Obstetrics and Gynecology, 68(2), 226-232.  
26. 
Emmons, S. L., Krohn, M., Jackson, M., & Eschenbach, D. A. (1988). Development of wound infections 
among women undergoing cesarean-section. Obstetrics and Gynecology, 72(4), 559-564.  
27. 
Roberts, S., Maccato, M., Faro, S., & Pinell, P. (1993). The microbiology of post-cesarean wound morbidity. 
Obstetrics and Gynecology, 81(3), 383-386.  
28. 
Rosene, K., Eschenbach, D. A., Tompkins, L. S., Kenny, G. E., & Watkins, H. (1986). Polymicrobial early 
postpartum endometritis with facultative and anaerobic bacteria, genital mycoplasmas, and Chlamydia 
trachomatis: treatment with piperacillin or cefoxitin. Journal of Infectious Diseases, 153(6), 1028-1037.  
29. 
Andrews, W. W., Shah, S. R., Goldenberg, R. L., Cliver, S. P., Hauth, J. C., & Cassell, G. H. (1995). 
Association of post-cesarean delivery endometritis with colonization of the chorioamnion by Ureaplasma 
urealyticum. Obstetrics and Gynecology, 85(4), 509-514. https://doi.org/10.1016/0029-7844(94)00436-H 
30. 
Keski-Nisula, L., Kirkinen, P., Katila, M. L., Ollikainen, M., Suonio, S., & Saarikoski, S. (1997). Amniotic fluid 
U. urealyticum colonization: significance for maternal peripartal infections at term. American Journal of 
Perinatology, 14(3), 151-156.  
31. 
Yoon, B. H., Romero, R., Park, J. S., Chang, J. W., Kim, Y. A., Kim, J. C., & Kim, K. S. (1998). Microbial 
invasion of the amniotic cavity with Ureaplasma urealyticum is associated with a robust host response in 
fetal, amniotic, and maternal compartments. American Journal of Obstetrics and Gynecology, 179(5), 
1254-1260. https://doi.org/Doi 10.1016/S0002-9378(98)70142-5 
32. 
Ledger, W. J. (2006). Prophylactic antibiotics in obstetrics-gynecology: a current asset, a future liability? 
Expert Review of Anti-Infective Therapy, 4(6), 957-964. https://doi.org/10.1586/14787210.4.6.957 
33. 
World Health Organization. (2015). Guideline: Managing Possible Serious Bacterial Infection in Young 
Infants When Referral is not Feasible. Retrieved August 22, 2018, from 

 
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http://apps.who.int/iris/bitstream/handle/10665/181426/9789241509268_eng.pdf;jsessionid=F74B4376
89D1CB960E2544DDF53FE5A6?sequence=1 
34. 
Sutton, A. L., Acosta, E. P., Larson, K. B., Kerstner-Wood, C. D., Tita, A. T., & Biggio, J. R. (2015). Perinatal 
pharmacokinetics of azithromycin for cesarean prophylaxis. American Journal of Obstetrics and 
Gynecology, 212(6), 812.  
35. 
Eberly, M. E., Eide, M. B., Thompson, J. L., & Nylund, C. M. (2015). Azithromycin in Early Infancy and 
Pyloric Stenosis. Pediatrics, 135(3), 483. https://doi.org/10.1542/peds.2014-2026 
36. 
Ray, W. A., Murray, K. T., Hall, K., Arbogast, P. G., & Stein, C. M. (2012). Azithromycin and the risk of 
cardiovascular death. New England Journal of Medicine, 366(20), 1881-1890.  
37. 
Svanström, H., Pasternak, B., & Hviid, A. (2013). Use of azithromycin and death from cardiovascular 
causes. New England Journal of Medicine, 368(18), 1704-1701. https://doi.org/10.1056/NEJMoa1300799 
38. 
Hoffman, M. K., Goudar, S. S., Kodkany, B. S., Goco, N., Koso-Thomas, M., Miodovnik, M., . . . Derman, R. J. 
(2017). A description of the methods of the aspirin supplementation for pregnancy indicated risk 
reduction in nulliparas (ASPIRIN) study. BMC Pregnancy and Childbirth, 17(1), 135. 
https://doi.org/10.1186/s12884-017-1312-x 
39. 
Goldenberg, R. L., Saleem, S., Ali, S., Moore, J. L., Lokangako, A., Tshefu, A., . . . McClure, E. M. (2017). 
Maternal near miss in low-resource areas. International Journal of Gynaecology and Obstetrics, 138(3), 
347-355. https://doi.org/10.1002/ijgo.12219 
40. 
Bonet, M., Souza, J. P., Abalos, E., Fawole, B., Knight, M., Kouanda, S., . . . Metin Gulmezoglu, A. (2018). 
The global maternal sepsis study and awareness campaign (GLOSS): study protocol. Reprod Health, 15(1), 
16. https://doi.org/10.1186/s12978-017-0437-8 
41. 
Albright, C.M., Has, P., Rouse D.J., Hughes B.L. (2018). Internal Validation of the Sepsis in Obstetrics 
 
Score to Identify Risk of Morbidity from Sepsis in Pregnancy. Obstetric Anesthesia Digest, 38 (1). 
 
https://doi.org/10.1097/01.aoa.0000529967.01647.fb. 
42.  
Bowyer L., Robinson H.L., Barrett H., Crozier T.M., Giles M., Idel I., Lowe S., Lust K., Marnoch  C.A., Morton 
 
M.R., et al. SOMANZ guidelines for the investigation and management sepsis in pregnancy. Aust. N. Z. J. 
 
Obstet. Gynaecol. 2017;57:540–551. doi: 10.1111/ajo.12646. 
 
 
 
 

 
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38 
APPENDIX 1. DESCRIPTION OF PARTICIPATING GLOBAL 
NETWORK SITES 
The Global Network for Women’s and Children’s Health Research (GN) was created as a private-public 
partnership between the U.S. National Institutes of Health (NIH) and the Bill and Melinda Gates 
Foundation in response to the alarming rates of morbidity and mortality in women and children and the 
lack of research expertise and infrastructure in the developing world. Its mission is to expand scientific 
knowledge, develop research infrastructures, and improve health outcomes by building research 
partnerships to conduct research on feasible, cost-effective, sustainable interventions to address the 
major causes of perinatal morbidity and mortality of women and children in the developing world. It is 
currently funded only by the Eunice Kennedy Shriver National Institute of Child Health and Human 
Development (NICHD). 
The current configuration of the GN is comprised of eight multidisciplinary research sites in seven 
developing countries (Bangladesh, Democratic Republic of Congo, Guatemala, India, Kenya, Pakistan, 
and Zambia), each with an established collaboration between an institution in the U.S. and one or more 
in the developing country. Each site has a U.S.-based senior principal investigator (PI) and a senior 
foreign investigator (SFI) based in the developing world, who lead a team of in-country research staff. 
In 2005, the GN implemented its first multicounty protocol, the First Breath (FB) study, a community-
based cluster trial to determine whether education and training in the American Academy of Pediatrics 
Neonatal Resuscitation Program (NRP) and the Essential Newborn Care Program (ENC) of the World 
Health Organization (WHO) reduced neonatal mortality (7 days) more than education and training in 
ENC alone. More than 3,700 birth attendants from 100 GN communities with > 150,000 deliveries were 
taught the appropriate procedures and provided with the necessary equipment to resuscitate infants at 
birth. Communities were randomized to ENC plus NRP or continued ENC. 
The GN has continued to build on the capacity developed in the FB trial through the implementation of 
more than 10 additional multicounty protocols to address priority research needs to improve maternal 
and child health in low-resource settings. Current projects include: 
• 
The Maternal Newborn Health Registry is a prospective, population-based study of 
pregnancies and their outcomes in low-middle income countries (DRC, Guatemala, India, 
Pakistan, Bangladesh, Zambia and Kenya). All pregnant women in participating clusters are 
registered and their outcomes tracked for 6 weeks post-delivery. The primary purpose of this 
prospective, population-based observational study of approximately 60,000 women per year is 
to quantify and understand the trends in pregnancy services and outcomes over time in 
defined, low-resource geographic clusters. The goal is to provide population-based statistics on 
stillbirths, neonatal and maternal mortality as the basis of health care policy. The data from the 
registry also provide the mortality and morbidity outcomes for Global Network trials and help 
investigators plan future studies for the Global Network. 
• 
Preterm birth remains the leading cause of neonatal mortality and long-term disability 
throughout the developed and developing world.  A growing body of evidence suggests that 1st 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
39 
trimester administration of low dose aspirin can reduce the rate of PTB substantially. The 
ASPIRIN Study is a prospective, randomized, placebo-controlled, double-masked, multi-center 
clinical trial to examine whether low dose aspirin initiated between 6 0/7 weeks- 12 6/7 weeks 
gestation reduces the risk of preterm birth. The study has enrolled 11,920 women across seven 
sites in Africa, Asia, and Latin America. 
• 
Attention is increasingly directed to the role of maternal nutrition during the 1st trimester for 
normal growth and development during the first thousand days, from conception to the child's 
second birthday. The primary hypothesis of the Women First: Preconception Maternal 
Nutrition study is that for women in poor communities, a comprehensive maternal nutrition 
intervention commencing at least 3 months prior to conception and continuing throughout 
pregnancy, will be associated with a significantly greater newborn length than for offspring 
whose mothers start to receive the same intervention at 12 weeks gestation or who do not 
receive the intervention at all. The results of this trial will make a major contribution to refining 
evidence-based strategies for maternal nutrition supplementation and evaluating the cost-
benefits of extending such strategies beyond pregnancy to virtually all women of child-bearing 
age, including adolescent girls. 
 
 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
40 
APPENDIX 2. SAMPLE INFORMED CONSENT 
Global Network for Women’s & Children’s Health Research 
Single oral dose of azithromycin 2 gm in laboring women to prevent neonatal infection/death 
and maternal peripartum infection/death  
 
INVESTIGATORS:  
[LIST SITE INVESTIGATORS] 
 
 
SPONSOR: 
The Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD) 
You are being asked to participate in a research study for pregnant mothers. This study is funded by the 
U.S. National Institutes of Health and the Bill and Melinda Gates Foundation. This form provides you 
with information about the study so that you can decide whether you would like to participate. A 
member of the research team will describe the study to you and answer all of your questions. Please 
read the information below and ask questions about anything you don’t understand before deciding 
whether or not to take part. You may also request that the research staff read the form to you.  
What is the purpose of the study? 
The purpose of this study is to learn whether an antibiotic, called azithromycin, given orally (by mouth) 
to pregnant women during labor can reduce the risk of infection for the woman and her baby. 
Who will be in the study? 
A total of 34,000 women will be enrolled in this study from eight sites in sub-Saharan Africa, South Asia, 
and Latin America. If needed, up to 2000 additional women across all sites who meet high-risk criteria 
will be enrolled (defined as 8 hours or more of membrane rupture before delivery or 18 hours or more 
of labor). In [insert site name], no more than [insert max sample size] will be enrolled.  
You qualify for this study if you are a pregnant woman of the legal age of consent who is in labor with 
one or more live fetuses and a pregnancy ≥28 weeks, plan to deliver vaginally in a health facility, have no 
known infections that require antibiotics, have no known problems taking azithromycin or similar 
antibiotics (such as amoxicillin), and have not used azithromycin, erythromycin, or similar antibiotic in 
the past 3 days. We will ask you some questions about your pregnancy and health status to make sure 
you qualify to participate. 
What will happen if I join this study? 
Before participating, you will be provided with information about the study procedures and given an 
opportunity to ask questions. If you qualify and agree to participate, you will be asked to sign this form 
to indicate your consent.  
If you agree to participate, you will be assigned to either the treatment group or the control group. The 
assignment is made randomly, like flipping a coin or choosing a grain of rice from a bag. The women in 
the treatment group will take four 500 mg azithromycin pills. For comparison, the women in the control 
group will take four pills that look identical to azithromycin but do not contain any medication. This will 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
41 
allow the researchers to compare how well azithromycin works to prevent infection in mothers and 
their babies. Neither you nor the study staff will know whether you are assigned to the treatment or 
control group.  
After you have been assigned to a treatment group, you will be given 4 small 500 mg pills to take by 
mouth. A member of the study team will watch you take the pills. After you take the pills, you will 
receive care during your labor, delivery, and recovery from the health facility staff, according to the local 
standard of care. It will take approximately 30 minutes to complete the consent form and take the pills. 
While you are at the health facility to deliver your baby, the study team will also collect: 
• 
Information about your health status during labor, at the time of delivery, and after delivery. 
This includes collecting your temperature and vital signs, such as heartrate and blood pressure; 
• 
Information about your baby’s health status during and after delivery. This includes collecting 
your baby’s temperature and vital signs, such as heart rate and blood pressure; 
• 
If you or your baby develop an infection before you are discharged from the health facility, a 
specimen will be collected to help identify the bacteria that is causing the infection. This may 
be blood sample, a urine sample, or a sample taken from the site of the infection (for example, 
pus from a wound or breast milk in the case of a breast infection).  
It will take no more than 30 minutes to collect health information about you and your baby. In the case 
of suspected infection, it may take an additional 30 minutes to collect samples from you or your baby. 
After delivery, a member of the study team will visit you a total of three times to assess the health 
status of you and your baby. These visits will be scheduled to take place at your home or a health facility 
at 3 days, 1 week (7 days) and 6 weeks (42 days) after delivery. If you or your baby are hospitalized at 
the scheduled time, the study team will visit you in the hospital. During the visit, the study team will 
assess you and your baby for current or past signs of infection. This will include collecting health 
information and measuring temperature for you and your baby. Each visit will take approximately 30 
minutes.  
A member of the study team will also contact you by phone at 14 days and 28 days after delivery to 
review the signs and symptoms of infection. If you do not have a phone, the study team will arrange to 
visit you at home or at the study facility. Each phone contact will take approximately 15 minutes. 
If a sign of infection is identified in you or your baby during the in-person visits or phone contact, you will 
be referred a health facility for further assessment. You will also be asked to provide a sample, such as 
blood, pus, or urine, to help identify the bacteria causing the infection. The samples will be labelled with 
a study identification number in place of your name or your baby’s name. Only dedicated members of our 
study team will have access to the samples.  
To ensure that we have accurate and complete information about the health of you and your baby, we 
will access and collect information from the medical records at the health facilities where you and your 
baby have received care. By agreeing to participate in this study, you are also agreeing to give 
permission for the study staff to access your medical records. We will take precautions to protect the 
information that is collected from your medical records. Only study staff will have access to this 
information. To further protect you and your baby, all of your information will be coded with a number 
in place of your name.  

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
42 
The local research staff have been selected because of their skills, knowledge, and familiarity with your 
community. The research staff are here to support you during the study and should be contacted 
between visits if you have any questions or concerns. 
What are the risks and discomforts 
Azithromycin is a sometimes used to treat infections in pregnant women and children. Research shows 
that the risks of taking azithromycin are minimal. A commonly reported side effect is gastric discomfort 
(nausea, stomach pain, diarrhea, vomiting); however, you will be given pills with a special coating which 
will help prevent stomach discomfort. There is also a small but rare risk that azithromycin could cause 
arrythmia (irregular or abnormal heartbeat) or an allergic reaction; therefore, you will not be able to 
participate if you have a known history of heart problems or have had a bad reaction to azithromycin or 
a similar drug in the past.  
If it is necessary to take a sample because of infection, you or your baby may feel temporary discomfort, 
but this will only last a few seconds. To minimize this, we will ensure research staff are well trained in 
the procedure.  
Another possible risk of participating in this study is that your name and personal information may be 
seen by persons who are not part of the project. To prevent this, you will be given an identification 
number that will be used in place of your name on all study documents.  
Information from this research study will be retained by [local institution] and RTI International in the 
United States (U.S.) and in the future may be included in a de-identified public use database managed by 
NICHD Data and Specimen Hub (DASH) in compliance with the U.S. National Institutes of Health (NIH) 
Public Access Policy. De-identified means that you and your baby will not be individually identified by 
name or other personal identifiers in the database. Your full name or any address details will not be 
included. Information released will not identify you or your baby’s participation in this research study.   
What are the benefits of participating? 
You will not receive any money from participating in this study, but your participation may provide 
important information that can be used in the future to prevent infection in mothers and babies. Also, 
there is preliminary information suggesting that the use of azithromycin in pregnancy can reduce the 
risk of maternal and infant infection. 
If new information about the benefits or risks of azithromycin use in pregnancy becomes available 
during the study, this information will be given to you by [Insert name of Senior Investigator] or his/her 
staff.  
Will I have to pay for anything? 
It will not cost you anything to be in the study.  
Is my participation voluntary? 
Taking part in this study is voluntary. You have the right to refuse to participate or to withdraw your 
participation at any time. If you refuse or decide to withdraw, you will not lose any benefits or rights to 
which you are entitled. These actions will not have any negative effect on the health care you receive 
from your local health providers. You will still receive your normal medical care.  
Can I be removed from this study?  

 
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43 
You will be withdrawn from the study if the research staff thinks that your participation may cause harm 
to you or your baby. The research staff may also remove you from the study for other reasons at their 
discretion. Also, the sponsor may stop the study at any time. 
What will happen if you are injured by this research? 
Although the risk of injury is expected to be very low, all research involves a chance that something bad 
might happen to you. Despite all safety measures, your participation could result in a reaction or injury. 
If you or your infant is injured as a result of your participation, you will be provided with emergency care 
by the study and referred to a doctor for ongoing care, if needed. Ongoing care will not be paid for by 
the study. [Insert name of Research Institution] and NICHD have not set aside funds to pay you for any 
such reactions, injuries or related medical care. However, by signing this form, you do not give up any of 
your legal rights.  
What should you do if you have additional questions? 
If you have questions about this study or a project-related injury, you should contact [investigator 
contact].  If you have questions about your or your baby’s rights as a project participant, please contact 
[insert ethics committee contact]. 
Agreement to be in this study 
I have read this paper about the study or it was read to me. I understand the possible risks and benefits 
of this study. I know that being in this study is voluntary and I choose to be in this study. I understand I 
will get a copy of this consent form. 
Signature (or thumbprint): 
 
 
 
 
________ 
Date: 
 
______  
 
 
 
 
(Mother) 
Print Name: 
 
 
 
 
 
 
 
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(Mother) 
Signature (or thumbprint): 
 
 
 
 
_________ 
Date: 
 
______  
 
 
 
 
(Parent/Guardian/Husband) 
Print Name: 
 
 
 
 
 
 
 
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(Parent/Guardian/Husband) 
 
Future Contact 
We may wish to contact you in the future about participating in other related research studies. Please 
indicate below if you are willing to be contacted. 
 Yes, I agree to be contacted 
 No, I do not agree to be contacted 
 
 

 
Azithromycin Protocol Version 1.6 (Dated 15 July 2022) 
44 
 
APPENDIX 3. SCHEDULE OF STUDY PROCEDURES 
 
ANC 
Visits 
During 
Labor/ 
Before 
Delivery 
After 
Delivery/ 
Before 
Discharge 
3-day 
postpartum 
(pp) 
7-day 
pp  
14-day 
pp 
28-day 
pp 
42-day 
pp 
As 
Needed 
Community Sensitization 
X 
 
 
 
 
 
 
 
 
Screening 
• Eligibility confirmation 
 
X 
 
 
 
 
 
 
 
• Clinical assessment 
 
X 
 
 
 
 
 
 
 
Consent 
 
X 
 
 
 
 
 
 
 
Randomization  
 
X 
 
 
 
 
 
 
 
Drug Administration 
 
X 
 
 
 
 
 
 
 
Baseline Data Collection 
• Sociodemographic 
information 
 
X 
X 
 
 
 
 
 
 
• Medical history 
 
X 
X 
 
 
 
 
 
 
• Labor and delivery 
information 
 
 
X 
 
 
 
 
 
 
Monitoring 
• Drug side effects  
 
X 
X 
X 
X 
 
 
X 
X 
• Maternal events during 
labor/delivery 
 
X 
X 
 
 
 
 
 
 
• Neonatal events during 
labor/delivery 
 
 
X 
 
 
 
 
 
 
• Maternal infection/sepsis 
assessment 
 
 
X 
X 
X 
 
 
X 
X 
• Neonatal infection/sepsis 
assessment 
 
 
X 
X 
X 
 
 
X 
X 
• Maternal death 
 
 
X 
X 
X 
 
 
X 
X 
• Stillbirth or neonatal death 
within 28 days of birth 
 
 
X 
X 
X 
X 
X 
X 
X 
• Infant mortality after 28 
days of birth 
 
 
 
 
 
 
 
X 
X 
• Pyloric stenosis 
 
 
X 
X 
X 
 
 
X 
X 
• Other maternal outcomes 
 
 
X 
X 
X 
 
 
X 
X 
• Other neonatal outcomes 
 
 
X 
X 
X 
 
 
X 
X 
• Unintended medical visits 
 
 
X 
X 
X 
 
 
X 
X 
Serious Adverse Events 
 
 
X 
X 
X 
 
 
X 
X 
 

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STATISTICAL ANALYSIS PLAN 
Prevention of maternal and neonatal death/infections with a single oral dose 
of azithromycin in women in labor (in low- and middle-income countries): a 
randomized controlled trial (A-PLUS) 
 
The A-PLUS Study 
SAP VERSION: 
Version 2.0 
 
SAP DATE: 
October 13, 2022 
 
SPONSOR: 
NICHD  
 
PREPARED BY: 
RTI International 
 
3040 Cornwallis Rd 
 
Research Triangle Park, NC 27709-2104 
 
AUTHOR (S): 
Tracy L. Nolen, Beth McClure, Janet Moore 
 
 
 
 
 
 
 
 
 
 
 

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Contents 
1. 
BACKGROUND AND PROTOCOL HISTORY 
6 
2. 
PURPOSE OF THE ANALYSES 
6 
3. 
STUDY OBJECTIVES AND OUTCOMES 
7 
3.1 
PRIMARY HYPOTHESIS AND ASSOCIATED OUTCOMES 
7 
3.2 
SECONDARY AIMS AND ASSOCIATED OUTCOMES 
8 
4. 
STUDY METHODS 
10 
4.1 
OVERALL STUDY DESIGN 
10 
4.2 
STUDY POPULATION 
11 
4.3 
STUDY ARM ASSIGNMENT AND RANDOMIZATION 
12 
4.4 
MASKING AND DATA LOCK 
12 
5. 
ANALYSIS POPULATIONS 
13 
6. 
SAMPLE SIZE DETERMINATION 
14 
6.1 
OVERALL (ALL-COMER) SAMPLE SIZE FOR PRIMARY OUTCOMES 
14 
6.2 
HIGH RISK COHORT SAMPLE SIZE FOR PRIMARY OUTCOMES 
16 
7. 
STATISTICAL / ANALYTICAL ISSUES 
17 
7.1 
GENERAL RULES 
17 
7.2 
ADJUSTMENTS FOR COVARIATES 
17 
7.3 
MISSING DATA APPROACHES: 
17 
7.4 
MULTICENTER STUDIES 
18 
7.5 
MULTIPLE COMPARISONS AND MULTIPLICITY 
18 
7.6 
MASKED DATA REVIEW 
18 
8. 
STUDY PARTICIPANTS, TREATMENT EXPOSURE AND COMPLIANCE 
19 
8.1 
PARTICIPANT DISPOSITION 
19 
8.2 
STUDY TREATMENT EXPOSURE AND COMPLIANCE 
19 

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8.3 
PROTOCOL DEVIATIONS 
19 
8.4 
DEMOGRAPHIC AND BASELINE CHARACTERISTICS 
19 
9. 
EFFICACY ANALYSES 
19 
9.1 
OVERVIEW OF EFFICACY ANALYSIS METHODS 
19 
9.2 
DEFINITION OF ANALYSIS VARIABLES 
20 
9.3 
PRIMARY ANALYSIS 
33 
9.4 
SECONDARY ANALYSES FOR HIGH RISK COHORT 
33 
9.5 
SECONDARY OUTCOME ANALYSES 
34 
10. 
SAFETY ANALYSIS: 
35 
11. 
INTERIM ANALYSES AND DATA MONITORING 
35 
12. 
CHANGES TO THE ANALYSES PLANNED IN THE PROTOCOL 
36 
13. 
REFERENCES 
36 
 
 
 

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LIST OF ABBREVIATIONS 
Acronym 
Definition 
AC 
All-Comers 
ACOG 
American Congress of Obstetricians and Gynecologists  
ANC 
Antenatal Care 
BP 
Blood Pressure 
DCC 
Data Coordinating Center 
DMC 
Data Monitoring Committee 
DMS 
Data Management System 
DRC 
Democratic Republic of the Congo 
EmONC 
Emergency Obstetric and Neonatal Care 
ERC 
Ethnical Review Committee 
FDA 
Food And Drug Administration 
FIGO 
International Federation of Gynecology and Obstetrics 
GA 
Gestational Age 
GEE 
Generalized Estimating Equation 
GI 
Gastrointestinal 
GN 
Global Network 
HR 
High Risk 
IRB 
Institutional Review Board 
ITT 
Intention to Treat 
JAMA 
Journal of the American Medical Association 
LIC 
Low income country 
LMIC 
Low middle income country 
LMP 
Last menstrual period 
MDG 
Millennium Development Goals 
mITT 
Modified intention to treat 
MNH 
Maternal and Neonatal Health 
NEJM 
New England Journal of Medicine 
NICHD 
Eunice Kennedy Shriver National Institute of Child Health and Human 
Development 
NIH 
National Institutes of Health 
NNT 
Number needed to treat 
OHRP 
U.S. Office of Research Protections 
PI 
Principal Investigator 
PP 
Per protocol 
pSBI 
possible serious bacterial infection 

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RCT 
Randomized Clinical Trial 
RTI 
Research Triangle International 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SC 
Steering Committee 
SFI 
Senior Foreign Investigator 
SMFM 
Society for Maternal-Fetal Medicine 
UAB 
University of Alabama at Birmingham 
UN 
United Nations 
WHO 
World Health Organization 
 
 
 
 

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1. BACKGROUND AND PROTOCOL HISTORY 
Background and Rationale 
Maternal infection and sepsis are a priority to reduce maternal and neonatal deaths. Compared to 
postpartum hemorrhage and preeclampsia/eclampsia, maternal infection has received less 
attention as a major cause of maternal death; proportionally it accounts for increasing deaths. In 
addition, maternal infection significantly increases the risk of neonatal sepsis which is one of the 
leading causes of neonatal death in LICs. Drawing from our findings on azithromycin prophylaxis for 
cesarean delivery in the US and data from another preliminary trial in The Gambia, Africa, we 
proposed to evaluate the role of a single oral dose of azithromycin (plus usual care) to prevent 
maternal death or peripartum sepsis and intrapartum/neonatal death or sepsis in laboring women 
as well as the targeted sub-population of those at the highest risk for infection because they have 
prolonged labor (≥18 hours) and/or prolonged membrane rupture (≥8 hours).  
Azithromycin is available as a generic agent with easy storage requirements. It has a bimodal half-
life of up to 70 hours in the non-pregnant population. Although its pharmacokinetic characteristics 
are not as well studied in the pregnant population, it is commonly used during pregnancy for 
treatment of chlamydia and other infections. Azithromycin covers a broad spectrum of bacteria 
(including gram-positive cocci, genital ureaplasmas and mycoplasmas, and certain gram-negative 
bacilli and anaerobes) that are associated with maternal infections which are often polymicrobial 
(chorioamnionitis, endometritis, and perineal/cesarean wound infection) and sepsis. In addition to 
the aforementioned organisms which may play a role in neonatal infection, azithromycin also has 
activity against Group B streptococcus which is a major cause of neonatal sepsis in developed 
countries and may be implicated in LICs and low-resources settings as well. Therefore, a successful 
prophylaxis intervention is likely to reduce infections and death and may also reduce health care 
costs and need for prolonged antibiotic therapy to treat infections which may be associated with 
resistance. 
Protocol History 
The protocol in place at time of study implementation was finalized in July 2022 under Protocol 
version 1.6.   
2. PURPOSE OF THE ANALYSES 
This statistical analysis plan (SAP) contains detailed information about statistical analyses to be 
performed to assess the primary and secondary hypotheses outlined in the protocol including one 
formal interim analysis. The results of these analyses will be included in the study manuscript(s). 
Result of the formal interim analysis will be provided only to the Data and Safety Monitoring Board 
until study completion or early termination. Additional exploratory analyses may be performed to 
support further manuscript development.  These analyses will not require an update to the SAP, but 
abbreviated analysis plans will be prepared prior to conducting those analyses.  

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3. STUDY OBJECTIVES AND OUTCOMES 
3.1 Primary Hypothesis and Associated Outcomes 
This study had two primary hypotheses, one with a maternal focus and one with a neonatal focus.  
1. First, a single, prophylactic intrapartum oral dose of 2 g azithromycin given to women in 
labor in low and middle-income settings will reduce maternal death or sepsis.  
2. Second, a single, prophylactic intrapartum oral dose of 2 g azithromycin given to women in 
labor in low and middle-income settings will reduce intrapartum/neonatal death or sepsis.   
 
The primary outcomes are:  
1. Maternal: Incidence of maternal death or sepsis within 6 weeks (42 days) post-delivery in 
intervention vs. placebo group. 
2. Neonatal: Incidence of intrapartum/neonatal death or sepsis within 4 weeks (28 days) post-
delivery in intervention vs. placebo group. 
 
Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from suspected 
or confirmed infection that occurs post-randomization during labor or the postpartum period. This 
WHO definition, endorsed by multiple global health organizations, will be operationalized as 
suspected or confirmed infection based on the presence of fever (>100.4° F/38° C) or hypothermia 
(<96.8° F/36° C) plus one or more signs of mild to moderate organ dysfunction including tachycardia 
(≥120 bpm), low BP (systolic <90 mm Hg), tachypnea (>24 breaths/min), altered mental 
status/confusion, reduced urinary output (<500 cc over 24 hours), jaundice, or renal failure (>1.2 
mg/dl). Components of peripartum infection which will be considered in making the diagnosis of 
suspected or confirmed infection include clinical chorioamnionitis, endometritis, wound infections 
(perineal or Cesarean), abdominal or pelvic abscess, mastitis/breast abscess or infection, 
pyelonephritis, pneumonia, and other bacterial infection. 
Neonatal sepsis is defined as a newborn with proven or possible serious bacterial infection (pSBI) or 
pneumonia, meningitis, urinary tract infection, or omphalitis. Possible serious bacterial infection will 
be determined using WHO criteria of pSBI defined as severe chest in-drawing, fever (temperature ≥ 
100.4° F/38 °C), hypothermia (temperature <95.9°F/35.5 °C), no movement at all or movement only 
on stimulation, feeding poorly or not feeding at all, and/or convulsions. Clinical and laboratory signs 
of infection will also be considered in making the diagnosis of suspected or confirmed infection. 
Only infections that occur post-randomization will count as study outcomes. 
Masked adjudication of key infection outcomes will be implemented by the DCC and investigators 
during the trial to standardize and enhance the reproducibility of trial results. In addition to the 
above specified criteria, reported antibiotic treatment and culture status will also be considered as 
part of the adjudication process in making the diagnoses for both maternal and neonatal sepsis.  
Local site investigators will review and validate the diagnosis for all participants identified to have 
the primary outcomes applying pre-specified criteria. These reviews will be conducted masked to 
treatment group. If a case requires additional input and cannot be adjudicated locally, then it will 

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move to central adjudication where the study PIs will review the participant’s information and make 
a final outcome determination. A random portion of the locally adjudicated cases will be selected 
for central review to ensure there are no systemic site difference in adjudication. This process will 
be coordinated by the DCC. 
3.2 Secondary Aims and Associated Outcomes 
The single dose of intrapartum azithromycin prophylaxis (2 g) will be compared to placebo to 
accomplish the following secondary aims:  
 
Main Secondary Aim for Women at High Risk for Infection Cohort:  
a. To evaluate whether the risk of maternal death or sepsis differs among laboring women with 
and without high-risk for infection (high risk is defined as women with prolonged labor [≥18 
hours] and/or prolonged membrane rupture [≥8 hours]). 
 
Other Secondary Specific Aims: 
b. To evaluate the effectiveness in reducing the risk of individual components of the primary 
composite endpoints (i.e., maternal death, maternal sepsis, intrapartum/neonatal death, 
neonatal sepsis including specifically all-cause neonatal deaths and neonatal deaths due to 
sepsis).  
c. To evaluate the effectiveness on the risk of intrapartum/neonatal death or sepsis in infants of 
laboring women at high-risk for infection because of prolonged labor (≥18 hours) and/or 
prolonged membrane rupture (≥8 hours). 
d. To evaluate the effectiveness on the risk of maternal infections including clinical 
chorioamnionitis, endometritis, wound infections (perineal or subsequent cesarean), 
abdominal or pelvic abscess, mastitis/breast abscess, pyelonephritis and pneumonia in all 
laboring women as well as in those at high-risk for infection. 
e. To evaluate the effectiveness in reducing the use of subsequent maternal antibiotic therapy 
from randomization to 42 days postpartum for any reason in all laboring women as well as in 
those at high-risk for infection. 
f. To compare the use of health care resources. Use of health care resources will be measured in 
terms of maternal and neonatal duration of hospital stay, unscheduled visits, readmissions, 
and admission to special care units/intensive care units in all laboring women and newborns 
as well as in those at high-risk for infection.  
g. To assess maternal GI symptoms (e.g., nausea, vomiting, and diarrhea) and other reported 
side effects, as well as infant pyloric stenosis and type of culture positive infections 
(antimicrobial resistance and maternal and infant microbiome diversity are compared in an 
ancillary study).  
h. To determine whether the effect on each of the primary outcomes differs by region (Africa, 
Latin America or Asia), any other antibiotic use during labor, and mode of delivery (cesarean 
or vaginal). Note that antibiotic use will not include use to treat any infections diagnosed after 
randomization as those will be outcomes. 
 
These secondary aims will be assessed using the following outcomes.  
• 
The individual components of the primary outcomes (i.e., maternal death, maternal 
sepsis, maternal death due to sepsis, intrapartum/neonatal death, neonatal sepsis including 
specifically all-cause neonatal deaths and neonatal deaths due to sepsis) 

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• 
Other Maternal Outcomes 
o Chorioamnionitis: Fever (>100.4°F/38°C) in addition to one or more of the 
following: fetal tachycardia ≥160 bpm, maternal tachycardia>100 bpm, 
tender uterus between contractions, or purulent/foul discharge from uterus 
prior to delivery. 
o Endometritis: Fever (>100.4°F/38°C) in addition to one or more of maternal 
tachycardia > 100 bpm, tender uterine fundus, or purulent/foul discharge 
from uterus after delivery.  
o Wound infection refers to purulent infection (superficial or deep infection 
including necrotizing fasciitis) of a perineal wound or wound of a cesarean 
with or without fever; In the absence of purulence, a wound infection 
requires presence of fever (>100.4°F/38°C) and at least one of the following 
signs of local infection: pain or tenderness, swelling, heat, or redness around 
the incision/laceration. 
o Other infections:  
 
Abdominopelvic abscess is evidence of pus in the abdomen or pelvis 
noted during open surgery, interventional aspiration or imaging;  
 
Mastitis/breast abscess or infection refers to fever (>100.4°F/38°C) and 
one or more of the following: breast pain, swelling, warmth, redness, or 
purulent drainage (for breast abscess). 
 
Pyelonephritis refers to fever (>100.4°F/38°C) and one or more of the 
following: urinalysis/dip suggestive of infection or costovertebral angle 
tenderness or confirmatory urine culture. 
 
Pneumonia refers to fever (>100.4°F/38°C) and clinical symptoms 
suggestive of lung infection including cough and/or tachypnea or 
radiological confirmation. 
o Use of subsequent maternal antibiotic therapy after randomization to 42 
days postpartum for any reason. 
o Time from drug administration until initial discharge after delivery (time 
may vary by site). 
o Maternal readmission within 42 days of delivery. 
o Maternal admission to special care units. 
o Maternal unscheduled visit for care. 
o Maternal GI symptoms including nausea, vomiting, and diarrhea and other 
reported side effects.  
o Maternal death due to sepsis using the Global Network algorithm of causes 
of death. 
• 
Other Neonatal Outcomes 
o Other neonatal infections (e.g. eye infection, skin infection, omphalitis, 
urinary tract infection, respiratory rate ≥60 breaths/minute) 

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o Neonatal initial hospital length of stay, defined as time of delivery until 
initial discharge (time may vary by site). 
o Neonatal readmission within 42 days of delivery. 
o Neonatal admission to special care units. 
o Neonatal unscheduled visit for care. 
o Neonatal death due to sepsis using the Global Network algorithm for causes 
of death. 
o Pyloric stenosis within 42 days of delivery, defined as clinical suspicion 
based on severe vomiting leading to death, surgical intervention 
(pyloromyotomy) as verified from medical records, or radiological 
confirmation. 
Detailed definitions for deriving the associated variables are included in Section 9.  
Type of culture positive infections, antimicrobial resistance and maternal and infant microbiome 
diversity were compared in an ancillary study and the associated analyses described in a separate 
analysis plan. 
4. STUDY METHODS 
4.1 Overall Study Design 
This study was a masked, placebo-controlled RCT of pregnant women laboring in health facilities of 
the eight Global Network sites/other health facilities. The investigational regimen is 2 g of 
azithromycin and the comparison arm is an identical placebo which is given orally. Both groups 
received the standard of care during labor, delivery and postpartum per local standards.  
Women were followed up until discharge and surveillance maintained (in-person), with visits at 3-
day, 7-day and 42-day postpartum to identify maternal or infant infection, unexpected medical 
visits, side effects, and other study outcomes. Supplemental phone contacts will be conducted at 14-
day and 28-day postpartum to review maternal and neonatal signs of infection using WHO criteria. If 
signs of infection are identified during the review, participants will be asked to visit a study facility 
for further assessment.  These supplemental contacts will reinforce the participants’ ability to self-
assess for signs of maternal and neonatal infection and improve identification of infection between 
the 7-day and 42-day postpartum visits.  If phone contact is not feasible, in-person visits may be 
conducted. 
A study schematic is shown below 
 

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Study Schematic 
Maternal and Neonatal Monitoring
Maternal and Neonatal Monitoring
Final Outcome Assessment 
(42-day postpartum)
Informed Consent
Consented*
STOP
Randomize
Refused
Ineligible
Eligible
Labor and Delivery Outcome 
(Daily before discharge)
Refer for 
clinical assessment 
and culture 
Community Sensitization
Screening
Early consent 
(site dependent)
Azithromycin Administration
Treatment 
Arm
Control
Arm
*If early consent, confirmation of eligibility and reconfirmation of consent required.
In-person Visits 
(3, 7, and 42-day postpartum)
Supplemental Infection Contact
(14 and 28-day postpartum)
Placebo Administration
Labor and Delivery Outcome 
(Daily before discharge)
In-person Visits 
(3, 7, and 42-day postpartum)
Supplemental Infection Contact
(14 and 28-day postpartum)
Refer for 
clinical assessment 
and culture 
Suspected
Infection
Final Outcome Assessment 
(42-day postpartum)
Suspected 
Infection
 
4.2 Study Population 
Pregnant women laboring in health facilities of the eight Global Network sites/other health facilities 
were eligible. Health facilities may include any hospitals and health centers where women routinely 
deliver within the study sites.     
Inclusion Criteria 
• 
Pregnant women in labor ≥28 weeks GA (by best estimate) with a pregnancy with one or 
more live fetuses who plan to deliver vaginally in a facility.  
• 
Admitted to health facility with clear plan for spontaneous or induced delivery. 
• 
Live fetus must be confirmed via presence of a fetal heart rate prior to randomization.  
• 
≥18 years of age or minors 14-17 years of age in countries where married or pregnant 
minors (or their authorized representatives) are legally permitted to give consent. 

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• 
Have provided written informed consent [Note: written informed consent may be 
obtained during antenatal care, but verbal re-confirmation may be needed (per local 
regulations) at the time of randomization]. 
 
Exclusion Criteria  
• 
Non-emancipated minors (as per local regulations) 
• 
Evidence of chorioamnionitis or other infection requiring antibiotic therapy at time of 
eligibility (however, women given single prophylactic antibiotics with no plans to 
continue after delivery should not be excluded).  
• 
Arrhythmia or known history of cardiomyopathy. 
• 
Allergy to azithromycin or other macrolides that is self-reported or documented in the 
medical record. 
• 
Any use of azithromycin, erythromycin, or other macrolide in the 3 days or less prior to 
randomization.  
• 
Plan for cesarean delivery prior to randomization. 
• 
Preterm labor undergoing management with no immediate plan to proceed to delivery.  
• 
Advanced stage of labor (>6 cm or 10 cm cervical dilation per local standards) and 
pushing or too distressed to understand, confirm, or give informed consent regardless 
of cervical dilation. 
• 
Are not capable of giving consent due to other health problems such as obstetric 
emergencies (for example, antepartum haemorrhage) or mental disorder. 
• 
Any other medical conditions that may be considered a contraindication per the 
judgment of the site investigator. 
• 
Previous randomization in the trial. 
4.3 Study Arm Assignment and Randomization 
Randomization of participants was carried out to obtain a 1:1 allocation ratio between the 
treatment and placebo arms. Randomization was stratified by site. A computer algorithm generated 
by the data coordinating center (DCC) created the random assignment to one of the treatment arms 
based on randomly permuted block design with randomly varied block sizes. The block sizes were 
known only by the DCC personnel.  Each site received a lot of the study drug to be distributed 
sequentially at the participating health facilities which are randomizing women for the study site. 
4.4 Masking and Data Lock 
Both the azithromycin and placebo were procured from the same manufacturer. The packaging was 
standardized across sites and will be labeled as: “Azithromycin 2 g or Placebo”, with the expiration 
data and a unique identifier. A certificate of authenticity was provided. 
Clinical and research staff involved with participant follow-up and/or clinical care as well as the 
women were masked to treatment status unless there was a serious adverse event potentially 
related to the treatment modality that required unmasking for safety reasons. There was one 
individual identified at each site for the role of pharmacist who monitored randomization, drug 
supply, and safety. Under the instruction of the DCC, the study pharmacist was trained and 

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authorized to apply un-masking procedures, if concerns about randomization or participant safety 
were identified. 
Data Lock: Most data were to be entered real time into a tablet-based electronic data capture 
system with paper forms provided as back up if needed.  Some delay in entry was anticipated for 
data obtained from records of readmissions/hospitalizations and unexpected visits for clinical care.  
At the end of the study, data were locked at the site level with final analysis data sets generated and 
locked once data from all sites have been received and all queries processed.  For each site, data 
collection for the protocol was stopped approximately 42 days after the last pregnant woman was 
randomized into the study at that site. Site will transmit all final data to the central database at the 
DCC within one month of this date, and data will be locked within two to four months post last 
follow-up visit.  
The outcomes of occurrence of infectious diseases and of pyloric stenosis will be determined 
programmatically where possible.  Any remaining cases will go through an adjudication process for 
final outcome determination.  The details of the adjudication process and the programmatic 
algorithm for determining endpoints or routing the cases for review are detailed in a separate 
adjudication plan. 
A single interim analysis is planned for this study. A data snapshot will be taken for that interim 
analysis.  Resolution of queries on and adjudication of data required for the interim analysis will be a 
focus prior to the snapshot but timely completion of the interim analysis will be prioritized over 
resolving all outstanding data issues.  The details and timeline of the interim analyses are described 
in section 11. For the interim analysis, only a senior statistician and the study statistician at the DCC 
and the Data Monitoring Committee (DMC) will be unmasked to analysis results. 
Otherwise, the study will not be unmasked until after study completion or early termination and 
subsequent data lock. 
5. ANALYSIS POPULATIONS 
As Treated (i.e. Safety [SAF]) Population 
The as-treated population will comprise all randomized participants and their infants who received 
any study treatment grouped by actual treatment received, irrespective of amount or duration of 
treatment received. Unless specified otherwise, data for this population will be analyzed as available 
(i.e. irrespective of protocol deviation occurrence, subsequent study participation termination, or 
study drug withdrawal). 
Intention to Treat (ITT) Population  
The primary analysis population will be the ITT population, which will include all randomized 
participants and their infants. All participants will be assigned to the arm to which they were 
randomized irrespective of treatment received. Unless specified otherwise, all participants will be 
included in analyses using this population (with data as available or imputed when specified per 

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section 7.3 and irrespective of protocol deviation occurrence, subsequent study participation 
termination, or study drug withdrawal).  
High Risk for Infection (HR) Population 
The HR sub-group will include all women in the ITT and their infants meeting criteria for being high 
risk (i.e., prolonged labor [≥18 hours] and/or rupture of membranes [≥8 hours]) at the time of 
randomization. All participants will be assigned to the arm to which they were randomized 
irrespective of treatment received. Unless specified otherwise, all participants will be included in 
analyses using this population (with data as available or imputed when specified per section 7.3 and 
irrespective of protocol deviation occurrence, subsequent study participation termination, or study 
drug withdrawal). 
Per Protocol (PP) Population  
This population will be used to conduct sensitivity analyses for the primary outcome. This 
population will include randomized participants that received all planned study drug and did not 
throw up within 15 minutes of taking study drug. Any individuals subsequently identified as 
ineligible for the study or who were documented as receiving azithromycin during study follow-up 
excluding study drug will be excluded. Participants will be grouped by actual treatment received. 
Additional exclusion reasons may be identified after completion of participant enrollment.  
The final determination of HR and PP analysis population membership will be via a masked data 
review prior to final study analyses in order to address any potential anomalous cases that may arise 
in this large of a study population (e.g. randomization/treatment of a woman who is discharged 
prior to delivery due to false labor or unresponsiveness to induction).  Final decisions with respect to 
populations used for the interim analyses as well as the final study analyses will be documented in 
an addendum to this SAP.  
6. SAMPLE SIZE DETERMINATION 
6.1 Overall (All-comer) Sample Size for Primary Outcomes 
Sample size estimates were generated to evaluate the potential benefits of peripartum prophylactic 
azithromycin to reduce the risk of adverse maternal and neonatal outcomes in two population 
cohorts of women in low and low-middle income settings. The first population of interest comprises 
all women delivering in facilities (overall).  
Power calculations for the study in the overall study population were generated for two primary 
outcome measures, one being the risk of maternal death or sepsis among women in the target 
population and the other being intrapartum /neonatal death or sepsis in infants delivered by 
women in the target population. For each of these outcome measures estimates of the required 
sample size needed to detect a risk reduction of 20%, 25%, and 30% were generated for power of 
0.8, 0.85, and 0.9. The risk of sepsis or maternal death was assumed to be 3%. That number is 
slightly higher than the current risk in the GN population, which is slightly less than 2%. However, we 
anticipate that with active surveillance rather than passive reporting based on the new WHO 

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definition of maternal sepsis (designed to catch more cases of sepsis), the risk will be at least 3%. For 
the neonatal outcome, the underlying risk of the combined outcome of intrapartum stillbirth, 
neonatal death, or sepsis was assumed to be between approximately 8% and 14%. This estimate 
was based on recent data from the GN indicating that the risk of intrapartum stillbirth is 
approximately 1.8% and the risk of neonatal death during the first 28 days after delivery is 2.3%; we 
assumed that the risk of sepsis not resulting in death is approximately 4% to 10%. The resulting 
required evaluable sample sizes are shown in Table 1 below. 
Table 1. Sample Sizes for the Overall Population, Alpha=0.05 
 
 
Evaluable Sample Size per Arm 
Baseline Risk 
Risk Reduction 
Power=0.80 
Power=0.85 
Power=0.90 
3% 
20% 
11455 
13103 
15334 
3% 
25% 
7133 
8159 
9548 
3% 
30% 
4815 
5508 
6446 
8% 
20% 
4096 
4686 
5483 
8% 
25% 
2554 
2921 
3419 
8% 
30% 
1727 
1975 
2311 
14% 
20% 
2204 
2521 
2950 
14% 
25% 
1377 
1575 
1842 
14% 
30% 
932 
1066 
1247 
 
The sample sizes shown above assume that the hypothesis test of interest is for the overall 
population and that the Type 1 error is controlled at the neonatal and maternal hypothesis level via 
testing each at an alpha = 0.05 level. Interest has been expressed for the overall study for being able 
to test the neonatal risk separately in south Asia and sub-Saharan Africa. Controlling the Type I error 
rate at the 0.025 level for each of those two areas within this sub-analysis of neonatal risk will be 
conducted to avoid multiple comparison concerns. The resulting sample sizes for that comparison 
are shown in Table 2 below. Note that this sample size would be the size required separately for the 
African and Asian sites. It is planned that each site will enroll approximately equal number of 
participants.  As such, approximately 37.5% of randomized mothers will be from sub-Saharan Africa 
and 50% will be from Asia.  This planned enrollment distribution is approximately equivalent to the 
rates of in-facility deliveries observed in the GN registry database. Specifically, approximately a third 
of the facility deliveries are conducted in sub-Saharan Africa and between 45% and 50% of the 
facility deliveries are conducted in Asia. These estimates are also consistent with the enrollment 
rates for the ASPIRIN study that is currently being conducted at these sites. Therefore, to get the 
total study sample size required, the numbers in the table would need to be multiplied by 3 to 
achieve reasonable power for the African sites. 
Table 2. Sample Sizes Within Region, Alpha=0.025 
 
 
Evaluable Sample Size per Arm 
Baseline risk 
Risk Reduction 
Power=0.80 
Power=0.85 
Power=0.90 
8% 
20% 
4961 
5607 
6477 
8% 
25% 
3093 
3496 
4038 
8% 
30% 
2091 
2363 
2729 

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14% 
20% 
2669 
3017 
3485 
14% 
25% 
1677 
1884 
2176 
14% 
30% 
1129 
1276 
1474 
 
Given the above information, we propose a sample size of 34,000 participants for the overall study. 
For the primary neonatal outcome of interest of intrapartum/neonatal sepsis or death, assuming 
that the loss to follow-up will be in the 2% to 3% range (consistent with the current ASPIRIN trial and 
the Global Network Maternal and Newborn Health registry), this sample size will be sufficient to 
provide 90% power to detect a 25% reduction in neonatal mortality and sepsis in the sub-Saharan 
African region and will provide 90% power to detect a 20% reduction in Asia assuming the baseline 
risk is at least 8%. For the primary maternal outcome of maternal death or sepsis, the sample size 
will provide 90% power to detect a 20% reduction from 3% in the population aggregated across all 
study sites. 
6.2 High Risk Cohort Sample Size for Primary Outcomes 
The second population of interest comprises the cohort of high-risk population of women delivering 
in facilities with high risk being defined as term and preterm pregnant women who experience 
prolonged labor or prolonged membrane rupture. As a major secondary aim, sample size estimates 
for the high-risk cohort were also obtained to ensure adequate power for this analysis.  
The primary objective of the high-risk component of the study is to test the effectiveness of a single 
oral dose of intrapartum azithromycin prophylaxis compared to placebo (all receive usual care) in 
reducing the risk of maternal sepsis or death in high risk laboring women. To estimate the sample 
size required for this component of the study, we assumed conservatively that the underlying risk of 
the combined outcome in the target population is 6%. Comparable to the other study estimates of 
the required sample size needed to detect a risk reduction of 20%, 25%, and 30% were generated 
for power of 0.8, 0.85, and 0.9. Because the interest for this study is in testing the hypothesis overall 
rather than by region, the estimates were generated using an alpha of 0.05. The results of these 
calculations are shown in Table 3 below. 
Table 3. Sample Sizes for the High-Risk Cohort, Alpha=0.05 
Baseline risk 
Risk Reduction 
Evaluable Sample Size per Arm 
 
 
Power=0.80 Power=0.85 Power=0.90 
6% 
20% 
5568 
6369 
7453 
6% 
25% 
3470 
3969 
4644 
6% 
30% 
2344 
2681 
3138 
 
Because a risk reduction of at least 30% is expected in this population, we propose a sample size for 
this HR cohort of 5,500 women. That sample size will be sufficient to detect a 30% risk reduction 
with a power of 0.85 with an assumed 2% to 3% loss to follow-up. Assuming that 20% of the women 
are at high risk, the overall study sample size of 34,000 should allow for sufficient enrollment into 
the HR cohort. 

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7. STATISTICAL / ANALYTICAL ISSUES 
7.1 General Rules 
All statistical computations will be performed and data summaries will be created using SAS 9.3 or 
higher. If additional statistical packages are required, these will be discussed in the study report. For 
summaries of study data, categorical measures will be summarized in tables listing the frequency 
and the percentage of participants in each study arm; continuous data will be summarized by 
presenting mean, standard deviation, median, minimum, and maximum; and ordinal data will be 
summarized by presenting median and the limits of the interquartile range. 
7.2 Adjustments for Covariates  
As this is a randomized trial and the randomization process was not compromised during execution, 
the treatment effect estimate from trial is unbiased, even without adjusting for any baseline 
covariates.  Therefore, no adjustments for covariates other than site as a randomization 
stratification factor are planned for the primary analysis.  However, baseline clinical and 
demographic variables that are known predictors of neonatal and maternal outcomes will be 
included in secondary analyses of intervention efficacy.   
7.3 Missing Data Approaches:  
The two primary reasons for missing data are expected to be 1) participant loss to follow-up and 2) 
lack of record availability of unscheduled clinic visit, hospitalizations and readmissions required to 
diagnose infections. 
Based on the historical data available from the MNH registry, we anticipate that the rate of missing 
responses due to loss to follow-up for maternal and neonatal morbidity and mortality measures are 
likely to be 2% or less.  This rate has been confirmed based on the pilot data where the current rate 
is 1.1% for participants loss to follow-up or who were withdrawn or withdrew themselves from 
study participation.   
All suspected infections that cannot be programmatically confirmed will go through a local site and 
central adjudication process to determine final outcome status using all available information as 
described in the adjudication plan.  We anticipate the rate of cases that cannot be adjudicated to be 
low; estimates of that proportion will be obtained using pilot data prior to any unmasking or 
analyses of the main trial data. 
For the primary analyses of sepsis and/or death in the ITT population, missing responses due to loss 
to follow-up and cases of suspected infection that cannot be adjudicated will be included via 
multiple imputation procedures. Multiple imputation assumes that the mechanism that caused the 
missing is independent of the value of the unobserved data (i.e. data are missing at random – MAR). 
Although there is potential that missing data due to record availability may not be MAR, we 
anticipate this proportion of missing data will be small and multiple imputation processes have been 
shown to be robust even if the missing mechanism is dependent on the values of the unobserved 
data, i.e. even is the missing data are non-ignorable non-response. As secondary/sensitivity 

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analyses, the primary analyses will also be repeated on the ITT populations using data as available 
and assuming all missing outcomes are sepsis or death as well as assuming all missing outcomes are 
not sepsis nor death. 
If more than 4% of data in within either or across both arms are missing for any reason, we will 
conduct additional sensitivity analysis on the effect of missing data on the inference including 
analyzing data as available and other approaches that will assess the robustness of the findings to 
different assumptions about the missing data.  The exact approaches for these sensitivity analyses 
will be determined based on the pattern of missingness and detailed in the final study report.  
7.4 Multicenter Studies 
For this multicenter study, randomization of study participants was stratified within site.  
Consequently, for all test-based analyses of treatment effect and model-based primary and 
secondary analyses, site will be included as a fixed effect in the models.  As an ancillary analysis 
associated with the primary outcome as well as secondary outcomes, we will examine descriptively 
whether the treatment effects vary across sites; however, these analyses of site differences in 
treatment effect are considered to be descriptive because sample sizes are likely inadequate to 
provide adequate power to detect site by treatment interaction effects.    
7.5 Multiple Comparisons and Multiplicity 
There is one formal hypothesis test for each of the maternal and neonatal population of the study.  
Each population will be analyzed and interpreted separately and thus analyses are not adjusted for 
multiplicity between these populations. The statistical test of the primary outcome in each 
population will be conducted at an overall 5% type I error rate (two-sided) with p-value allocation 
between the interim and final analyses as detailed in Section 11. 
The study sample size was determined to provide sufficient power to test for treatment effects 
within the high-risk cohort as the main secondary aim and also within region.  As these are 
secondary aims, no adjustment multiplicity was applied to the planned primary study analyses. 
However, to avoid over-interpretation of regional findings the sub-analysis of the primary neonatal 
outcome within the Asian and African regions will be conducted controlling the Type I error rate at 
the 0.025 level. 
However, all other analyses of secondary outcomes are exploratory in nature; therefore, p-values 
and confidence intervals are provided for descriptive purposes only. Additionally all p-values 
provided for any baseline and demographic characteristics and safety parameters will be for 
descriptive purposes only. As such, unless otherwise specified, p-values presented will be on a per 
analysis basis, with no further control for multiple tests.  
7.6 Masked Data Review 
Masked data review processes will be performed throughout the conduct of the study to define 
study analysis populations and to adjudicate key outcome variables.  With respect to the outcome 
adjudication process, details will be defined in the adjudication plan.  Prior to the interim and final 

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analyses, masked reviews of protocol deviations and other study operational aspects and data will 
be reviewed to address any questions about data handling for analyses (e.g. analysis population 
membership) Detailed documentation of the masked data review and resulting decisions will be 
described in a SAP addendum. The study team individuals (i.e. statisticians) privy to interim analysis 
results may generate reports for subsequent masked data reviews but will not be responsible for 
any decisions making in these subsequent reviews. 
8. STUDY PARTICIPANTS, TREATMENT EXPOSURE AND COMPLIANCE 
8.1 Participant Disposition   
Participant eligibility status will be summarized by study arm and overall disposition of study 
participants will be described using a standard CONSORT diagram. The number of participants 
randomized; receiving study therapy; and completing the study follow-up will be summarized by 
study arm. Reasons for study withdrawal will also be summarized by treatment arm to assess 
whether they are balanced across treatment arm and to assure that any imbalances are unlikely to 
affect inference. 
8.2 Study Treatment Exposure and Compliance 
Each participant will receive a single dose of azithromycin or placebo in the form of 4 capsules at 
time of randomization during labor. Treatment exposure with respect to the number of randomized 
participants treated, if they received their assigned treatment or not, and if they vomited shortly 
after delivery will be summarized. While treatment compliance in dosing is anticipated, the number 
of pills taken will also be summarized. 
8.3 Protocol Deviations 
Protocol deviations will be summarized by treatment arm and by site with information such as type 
of deviation and time of occurrence. Incidence rate of protocol deviations will also be summarized 
overall and for each protocol deviation category by treatment arm. Incidence rate of protocol 
deviations will be calculated as: number of deviations divided by the number of participant weeks at 
the site.  
8.4 Demographic and Baseline Characteristics 
Demographic and baseline clinical characteristics for the study participants will be summarized by 
treatment group using the general analysis rules describe above for the ITT population.  Variables of 
interest include maternal age, maternal education, marital status, parity, occurrence of any infection 
during pregnancy, and if last pregnancy resulted in live birth.  
9. EFFICACY ANALYSES 
9.1 Overview of Efficacy Analysis Methods 
The data will be summarized by treatment arm, overall and by region.  All model-based analyses and 
test-statistics examining the treatment effect will adjust for GN site as a randomization variable. 
Additional details are presented in the sections below. 

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9.2 Definition of Analysis Variables 
As clinical assessments/diagnoses and associated care may lag behind actual occurrence, any 
infection events, antibiotic use, or other medical care (e.g. admissions, unscheduled visits) 
documented prior to the end of the relevant visit window will be counted. Mortality outcomes will 
be defined in accordance with traditional Global Network algorithms only including events occurring 
specifically within the window detailed in the outcome definition below.  
Additionally, most infections are expected to occur within the first week following delivery.  
Therefore, mothers or infants that are lost to follow-up after completion of a Day 7 visit with no 
signs or symptoms of infection prior to becoming lost to follow-up will be considered to meet 
criteria to have the primary outcome ascertained as no infection or death. Mothers or infants lost to 
follow-up prior to completion of a Day 7 visit with no signs or symptoms of infection will be consider 
to have missing outcomes. 
 
 

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Variable 
Type 
Definition 
Primary Outcomes 
Maternal death and/or 
sepsis through 42 days 
Primary Composite Outcome 
Binary 
The event will be defined as “Yes” if either component of this composite outcome is 
“Yes” and “No” if both components of the composite are “No.”  Any subsequent missing 
values will be included in the primary analyses using multiple imputation procedures.  
Analysis population(s): ITT (all-comer and high risk; with and without imputation), Per-
Protocol 
Intrapartum/neonatal death 
and/or sepsis through 28 
days Primary Composite 
Outcome 
Binary 
The event will be defined as “Yes” if either component of this composite outcome is 
“Yes” and “No” if both components of the composite are “No.”  Any subsequent missing 
values will be included in the primary analyses using multiple imputation procedures.  
Analysis population(s): ITT (all-comer and high risk; with and without imputation), Per-
Protocol 
Secondary Outcomes 
Maternal death through 42 
days Component 
Binary 
The event will be defined as “Yes” if the woman dies prior to 42 days after delivery and 
“No” otherwise.  This outcome measure will be obtained from form MN06 (i.e. presence 
of a form indicating a death has occurred).  If the 42-day outcome is missing and the 
woman was alive at the last known follow-up, this outcome will be treated as missing 
when analyzed alone. 
Analysis population(s): ITT (all-comer and high risk), As Treated  

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Variable 
Type 
Definition 
Maternal death due to 
sepsis through 42 days  
Binary 
The event will be defined as “Yes” if the woman dies prior to 42 days after delivery with 
the cause of death determined to be sepsis and “No” otherwise (i.e. if the women is 
alive or died due to other causes).  This outcome measure will be obtained from form 
MN06 (i.e.as defined by the MNH algorithm).  If the 42-day outcome is missing and the 
woman was alive at the last known follow-up, this outcome will be treated as missing 
when analyzed alone. 
 
Analysis population(s): ITT (all-comer and high risk) 

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Variable 
Type 
Definition 
Maternal sepsis through 42 
days Component 
Binary 
The event will be defined as “Yes” if the woman is diagnosed with sepsis prior to 42 
days after delivery and “No” otherwise.   
 
The details of defining this outcome are in the adjudication plan.  In brief, where 
possible the outcome will be defined programmatically per the algorithm defined in the 
adjudication plan with cases that are unable to be programmatically determined route 
to adjudication.  For the adjudicated outcomes, the value will be determined based on 
the reported final outcome reported by the site via form AZ13 (and confirmed via 
central adjudication).  If the final outcome is “Insufficient data to make a 
determination,” the outcome will be treated as missing. For sepsis confirmed by 
algorithm, the date of sepsis will be the visit date when the first confirmation criterion is 
met. For sepsis confirmed by adjudication the diagnosis date will be the diagnosis date 
recorded on the maternal adjudication form (AZ13A). If the adjudication diagnosis date 
is before delivery, then it is set to delivery date. If the adjudication diagnosis date is 
more than 3 days after the last unplanned care date with adjudication triggers, then it is 
set to the maximum of delivery date and unplanned care visit with adjudication triggers 
presentation and discharge dates. If the algorithm date is 1, 2 or 3 days before delivery 
and is equal to the first unplanned care date then the diagnosis date is set to delivery 
date. Analysis population(s): ITT (all-comer and high risk)  
Intrapartum/neonatal death 
through 28 days Component 
Binary 
The event will be defined as “Yes” if there is any intrapartum pregnancy loss including 
stillbirth after randomization or if there is neonatal death prior to 28 days after delivery 
and “No” otherwise.  This outcome measure will be obtained from form MN05 (i.e. 
presence of a form indicating a death has occurred).    If the 28-day and 42-day 
outcomes are both missing this outcome will be treated as missing when analyzed 
alone. 
Analysis population(s): ITT (all-comer and high risk), As Treated 

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Variable 
Type 
Definition 
Neonatal sepsis through 28 
days Component 
Binary 
The event will be defined as “Yes” if the infant is diagnosed with sepsis prior to 28 days 
after delivery and “No” otherwise.   
 
The details of defining this outcome are in the adjudication plan.  In brief, where 
possible the outcome will be defined programmatically per the algorithm defined in the 
adjudication plan with cases that are unable to be programmatically determined route 
to adjudication.  For the adjudicated outcomes, the value will be determined based on 
the reported final outcome reported by the site via form AZ13 (and confirmed via 
central adjudication).  If the final outcome is “Insufficient data to make a 
determination,” the outcome will be treated as missing. For sepsis confirmed by 
algorithm, the date of sepsis will be the visit date when the first confirmation criterion is 
met. For sepsis confirmed by adjudication the diagnosis date will be the diagnosis date 
recorded on the neonatal adjudication form (AZ13B). If the adjudication date is before 
the delivery date, then the sepsis diagnosis date will be the delivery date. If the 
adjudication sepsis diagnosis date is 4 or more days after the maximum visit date for 
delivery or unplanned care forms with adjudication triggers or the diagnosis date is 
missing, then the sepsis diagnosis date will be the maximum visit date from forms with 
adjudication triggers.  
Analysis population(s): ITT (all-comer and high risk) 
 
 

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Variable 
Type 
Definition 
All cause neonatal death 
through 28 days  
Binary 
The event will be defined only for live births. It will be defined as “Yes” if there is any 
subsequent neonatal death prior to 28 days after delivery and “No” otherwise.  This 
outcome measure will be obtained from forms MN05 (i.e. presence of a form indicating 
a death has occurred and defined only for individuals with response to question A.2 
“Was the death a stillbirth” of No).  If the 28-day and 42-day outcomes are both 
missing, this outcome will be treated as missing. 
Analysis population(s): ITT (all-comer and high risk), As Treated  
Neonatal deaths due to 
sepsis through 28 days  
Binary 
The event will be defined only for live births. It will be defined as “Yes” if there is any 
subsequent neonatal death determined to be due to sepsis prior to 28 days after 
delivery and “No” otherwise (i.e. if the infant is alive or died due to other causes).  This 
outcome measure will be obtained from forms MN05 (i.e. as defined by the MNH 
algorithm and defined only for individuals with response to question A.2 “Was the 
death a stillbirth” of No).  If the 28-dayand 42-day outcomes are both, this outcome will 
be treated as missing. 
Analysis population(s): ITT (all-comer and high risk) 

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Variable 
Type 
Definition 
Maternal Chorioamnionitis 
Binary 
The event will be defined as “Yes” if the mother is diagnosed with chorioamnionitis 
prior to delivery and “No” otherwise.   
 
The details of defining this outcome are in the adjudication plan.  In brief, where 
possible the outcome will be defined programmatically per the algorithm defined in the 
adjudication plan with cases that are unable to be programmatically determined route 
to adjudication.  For the adjudicated outcomes, the value will be determined based on 
the reported final outcome reported by the site via form AZ13 (and confirmed via 
central adjudication).  If the final outcome is “Insufficient data to make a 
determination,” the outcome will be treated as missing.  
Analysis population(s): ITT (all-comer and high risk) 
Maternal Endometritis 
Binary 
The event will be defined as “Yes” if the mother is diagnosed with endometritis prior to 
day 42 and “No” otherwise.   
 
The details of defining this outcome are in the adjudication plan.  In brief, where 
possible the outcome will be defined programmatically per the algorithm defined in the 
adjudication plan with cases that are unable to be programmatically determined route 
to adjudication.  For the adjudicated outcomes, the value will be determined based on 
the reported final outcome reported by the site via form AZ13 (and confirmed via 
central adjudication).  If the final outcome is “Insufficient data to make a 
determination,” the outcome will be treated as missing.  
Analysis population(s): ITT (all-comer and high risk) 

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Variable 
Type 
Definition 
Wound infection (cesarean 
or perineal) 
Binary 
The event will be defined as “Yes” if the mother is diagnosed with wound infection 
(cesarean or perineal) prior to day 42 and “No” otherwise.   
 
The details of defining this outcome are in the adjudication plan.  In brief, where 
possible the outcome will be defined programmatically per the algorithm defined in the 
adjudication plan with cases that are unable to be programmatically determined route 
to adjudication.  For the adjudicated outcomes, the value will be determined based on 
the reported final outcome reported by the site via form AZ13 (and confirmed via 
central adjudication).  If the final outcome is “Insufficient data to make a 
determination,” the outcome will be treated as missing.  
Analysis population(s): ITT (all-comer and high risk) 

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Variable 
Type 
Definition 
Maternal Other Infections 
Binary 
The event will be defined as “Yes” if the criteria for any of the following infections are 
met prior to day 42 and “No” otherwise. Indicators will be also defined separately for 
each infection type.  
• 
Abdominopelvic abscess  
• 
Mastitis/breast abscess or infection 
• 
Pyelonephritis 
• 
Pneumonia 
• 
Other bacterial infection 
The details of defining this outcome are in the adjudication plan.  In brief, where 
possible the outcome will be defined programmatically per the algorithm defined in the 
adjudication plan with cases that are unable to be programmatically determined route 
to adjudication.  For the adjudicated outcomes, the value will be determined based on 
the reported final outcome reported by the site via form AZ13 (and confirmed via 
central adjudication).  For each type, if the final outcome is “Insufficient data to make a 
determination,” the outcome will be treated as missing. For the overall, if no criteria 
were met for any of the infections and at least one is “Insufficient data to make a 
determination,” then composite outcome will be treated as missing.  
Analysis population(s): ITT (all-comer and high risk) 
Maternal antibiotic therapy 
after randomization to 42 
days for any reason 
Binary 
The outcome will be defined as “Yes” if any antibiotic therapy is reported on AZ03 
during initial hospitalization, or on AZ05a, AZ06 or AZ07 during follow-up and prior to 
day 42 and “No” otherwise.  The outcome will only be missing for mothers that are lost 
to follow-up prior to completion of a Day 7 visit and had no antibiotic use reported prior 
to becoming LTF. 
Analysis population(s): ITT (all-comer and high risk) 

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Variable 
Type 
Definition 
Time from drug 
administration until initial 
discharge after delivery 
(days) 
Continuous 
Defined as the date/time of initial discharge reported on AZ03 or AZ07 – date/time of 
study drug administration reported on AZ02  
Analysis population(s): ITT (all-comer and high risk) 
Maternal readmission within 
42 days of delivery 
Binary 
Only defined for women who were initially discharged from the hospital following 
delivery as documented on AZ03 or AZ07 (i.e. women that die during the initial 
hospitalization for delivery will be excluded from the numerator and denominator). The 
outcome will be defined as “Yes” if the location of any subsequent study visit on AZ05a 
is In-patient (hospitalized), or if there is an AZ07 form where the woman is noted as 
admitted or has a non-missing admission date; and “No” otherwise. The outcome will 
only be missing for mothers that are lost to follow-up prior to completion of a Day 7 
visit and had no readmission reported prior to becoming LTF.  
Analysis population(s): ITT (all-comer and high risk) 
Maternal admission to 
special care units 
Binary 
The outcome will be defined as “Yes” if there is an AZ03 or AZ07 form where the 
woman is noted as having received care or treatment at an intensive care or specialized 
care unit while at the facility; and “No” otherwise. The outcome will only be missing for 
mothers that are lost to follow-up prior to completion of a Day 7 visit and had no 
specialized care reported prior to becoming LTF.  
Analysis population(s): ITT (all-comer and high risk) 

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Variable 
Type 
Definition 
Maternal unscheduled visit 
for care 
Binary 
The outcome will be defined as “Yes” if occurrence of unscheduled care after initial 
delivery discharge is reported on either AZ05a (with a non-missing date of care) or on 
AZ07 form (with a non-missing exact or estimated date of care); and “No” otherwise. 
The outcome will only be missing for mothers that are lost to follow-up prior to 
completion of a Day 7 visit and had no unscheduled visit for care reported prior to 
becoming LTF.  
Analysis population(s): ITT (all-comer and high risk) 
Maternal GI symptoms 
including nausea, vomiting, 
and diarrhea and other 
reported side effects.  
 
Binary 
The outcome will be defined as “Yes” if vomiting or diarrhea are reported after delivery 
on AZ03 or AZ05a; an unscheduled care visit for nausea, vomiting, or diarrhea is 
reported on AZ05a; or an unscheduled care visit for nausea, vomiting and/or diarrhea is 
reported on AZ07; or a mechanistically-related AE is reported (e.g. abdominal pain); and 
“No” otherwise. The outcome will only be missing for mothers that are lost to follow-up 
prior to completion of a Day 7 visit and had no symptoms or side effects reported prior 
to becoming LTF.  
Analysis population(s): As Treated 
Neonatal Other Infections 
Binary 
The event will be defined as “Yes” if any infection is reported that does not qualify for 
sepsis prior to day 28 and “No” otherwise.  Other neonatal infections include eye 
infection with swelling and drainage, skin infection with 10 or more pustules or bullae, 
omphalitis, urinary tract infection, pyelonephritis or kidney infection, pneumonia or 
lung infection, meningitis, other infection documented in clinical record or respiratory 
rate ≥ 60. The outcome will only be missing for infants that are lost to follow-up prior to 
completion of a Day 7 visit and neonatal deaths prior to 7 days that do not quality for 
sepsis or other infections.  
Analysis population(s): ITT (all-comer and high risk) 

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Variable 
Type 
Definition 
Neonatal initial hospital 
length of stay 
 
Ordinal 
Defined as the date/time of initial discharge reported on AZ04 or AZ08 – date/time of 
delivery reported on AZ03 
Analysis population(s): ITT (all-comer and high risk) 
Neonatal readmissions 
within 42 days of delivery 
Binary 
Only defined for live births who were initially discharged from the hospital following 
delivery as documented on AZ04 or AZ08 (i.e. stillbirths or infants that die during the 
initial hospitalization for delivery will be excluded from the numerator and denominator). 
The outcome will be defined as “Yes” if the location of any subsequent study visit on 
AZ05b is In-patient (hospitalized), or if there is an AZ08 form where the infant is noted 
as admitted or has a non-missing admission date; and “No” otherwise. The outcome will 
only be missing for infants that are lost to follow-up prior to completion of a Day 7 visit 
and had no readmission reported prior to becoming LTF.  
Analysis population(s): ITT (all-comer and high risk) 
Neonatal admission to 
special care units  
Binary 
The outcome will be defined as “Yes” if there is an AZ04 or AZ08 form where the infant 
is noted as having received care or treatment at an intensive care or specialized care 
unit while at the facility; and “No” otherwise. The outcome will only be missing for 
infants that are lost to follow-up prior to completion of a Day 7 visit and had no 
specialized care reported prior to becoming LTF.  
Analysis population(s): ITT (all-comer and high risk) 

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Variable 
Type 
Definition 
Neonatal Unscheduled 
Clinical or ER Visit 
Binary 
The outcome will be defined as “Yes” if occurrence of unscheduled care after initial 
delivery discharge is reported on either AZ05b (with a non-missing date of care) or there 
is an AZ08 form (with a non-missing exact or estimated date of care); and “No” 
otherwise. The outcome will only be missing for infants that are lost to follow-up prior 
to completion of a Day 7 visit and had no unscheduled care visit reported prior to 
becoming LTF.  
Analysis population(s): ITT (all-comer and high risk) 
Pyloric stenosis within 42 
days of delivery 
Binary 
The event will be defined only for live births. The event will be defined as “Yes” if the 
infant is diagnosed with pyloric stenosis prior to day 42 and “No” otherwise.   
 
The details of defining this outcome are in the adjudication plan.  In brief, where 
possible the outcome will be defined programmatically per the algorithm defined in the 
adjudication plan with cases that are unable to be programmatically determined route 
to adjudication.  For the adjudicated outcomes, the value will be determined based on 
the reported final outcome reported by the site via form AZ13 (and confirmed via 
central adjudication).  If the final outcome is “Insufficient data to make a 
determination,” the outcome will be treated as missing.  
Analysis population(s): As Treated 

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9.3 Primary Analysis 
The primary outcomes of incidence of maternal death or sepsis and incidence of 
intrapartum/neonatal death or sepsis will be compared between the two treatment arms using 
generalized linear models. These generalized linear models will be fit with each binary outcome 
separately as the outcome measure. Estimates of relative risk and associated 95% confidence 
intervals will be reported. The model will include terms for treatment and site. As randomization 
occurs at the pregnancy level and approximately 1-2% of pregnancies are anticipated to be multiple 
gestations, models for neonatal outcomes will account for correlation among multiples assuming an 
exchangeable covariance structure. If a model for neonatal outcomes has convergence issues, then 
the generalized linear model will be fit without the adjustment for correlation among multiples. For 
the two primary outcomes, these analyses will be conducted using the ITT population and the p-
values associated with the treatment term will be used to formally test each of the two primary 
hypotheses at the alpha = 0.05 level.  
The primary analyses using the ITT population will use multiple imputation for missing outcomes 
implemented separately for mothers vs. infants via logistic regression imputation using site and 
high-risk status prior to randomization as covariates. As sensitivity analyses, the primary outcomes 
will also be analyzed without imputation for individuals in the ITT population, without imputation 
for individuals in the per-protocol population; and in the ITT population assuming all missing 
outcomes are sepsis or death as well as assuming all missing outcomes are not sepsis nor death. 
As secondary analyses of the primary outcomes, the models will be run including region (Africa, 
Latin America, or Asia) and a treatment by region interaction term. If the interaction term has a 
p<0.1, then effect estimates and associated confidence intervals will be reported by region with 
treatment effect within region for Africa and Asia tested at the 0.025 level.  
For secondary publications, additional exploratory models will also be run including individually: 1) a 
treatment by site interaction term, 2) any other antibiotic use during labor (yes or no) and its 
interaction with treatment, and 3) mode of delivery (cesarean or vaginal) and its interaction with 
treatment.  If the interaction term for any of these models has a p<0.1, then effects will also be 
reported by the relevant subgroups. These exploratory secondary models will also include any 
demographic or clinical variables found to differ significantly between the treatment arms in the 
preliminary analyses described above.  From each final model, adjusted relative risk estimates for 
treatment will be obtained.   Kaplan-Meier survival curves will be fit to the data in order to get 
cumulative incidence curves by treatment group of the timing of the first occurrence of maternal 
death or sepsis and intrapartum/neonatal death or sepsis. 
9.4 Secondary Analyses for High Risk Cohort 
The major secondary aim is assessing the two primary outcomes (i.e. incidence of maternal death or 
sepsis and incidence of intrapartum/neonatal death or sepsis) in the women at high risk for infection 
cohort. Analyses for this aim will be the same as that specified in 10.4 but subset only on women 
that meet the high risk definition prior to randomization.  

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Analyses will also assess if the treatment effect differs between the HR cohort vs. non-high risk 
women where non-high risk women comprise all women and their infants in the ITT population that 
delivered prior to meeting criteria for high risk (i.e. they delivered after < 18 hours of labor and < 8 
hours post-rupture of membranes). Specifically, the model for the primary analysis of both the 
maternal and neonatal primary outcomes will be run including a treatment by risk status interaction 
term and excluding any data from individuals that meet high risk criteria after randomization.  
The exclusion of data from individuals meeting high risk criteria between randomization and delivery 
is intended to provide the most distinct groups regarding the HR risk cohort to non-high risk women 
comparison. As this exclusion is based on a post-randomization event, sensitivity analyses will be 
conducted to examine any treatment group differences in meeting high risk criteria post 
randomization and if there is a difference, to determine the potential magnitude of impact this 
difference has on treatment effect.   
An exploratory analysis will also be completed that assesses if there is a difference in treatment 
effect between women randomized prior to high risk classification vs. those randomized after high 
risk classification. Finally, an exploratory analysis will be conducted that assesses the definition of 
high risk to determine if there is a broader group of individuals that remain at higher risk of infection 
and/or are observed to have a greater treatment effect (e.g. prolonged labor [≥18 hours] and/or 
rupture of membranes [≥8 hours]). 
9.5 Secondary Outcome Analyses  
Binary secondary outcomes (e.g. individual components of the primary outcome, all other infection 
indicators, use of antibiotics, maternal and neonatal readmission as well as admission special care 
unit, maternal GI symptoms, and pyloric stenosis) will be analyzed in a similar manner to the 
primary analysis of the primary outcomes.  Models will be focused on providing estimates of relative 
risk and associated confidence intervals as opposed to being used for formal tests of hypothesis. If 
regional differences are observed for the primary outcome, then region-specific models for all 
secondary outcomes will be run in order to get region-specific estimates of relative risk.  
For secondary publications, secondary outcomes may also be explored using additional exploratory 
models including individually: 1) a treatment by site interaction term, 2) any other antibiotic use 
during labor (yes or no) and its interaction with treatment, and 3) mode of delivery (cesarean or 
vaginal) and its interaction with treatment.  If the interaction term for any of these models has a 
p<0.1, then effects will also be reported by the relevant subgroups. These exploratory secondary 
models will also include any demographic or clinical variables found to differ significantly between 
the treatment arms in the preliminary analyses described above.  From each final model, adjusted 
relative risk estimates for treatment will be obtained. 
For the outcome of time from drug administration until initial discharge after delivery and the 
outcome of neonatal initial hospital length of stay, the same analysis steps will be employed but 
using models appropriate for the distribution of these variables (Brock 2011).  Specifically, Kaplan-
Meier survival curves will be fit to the data in order to get cumulative incidence curves by treatment 
group of hospital discharge, obtained by treating in-hospital mortality as a competing risk. 

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10. SAFETY ANALYSIS:  
No formal safety analyses are planned as a part of this study, although SAEs and side effects will be 
summarized.  No formal hypothesis tests will be conducted, but descriptive p-values generated 
using Cochran-Mantel-Haenszel statistics with stratification by GN site will be generated.  
11. INTERIM ANALYSES AND DATA MONITORING 
 
Additionally, one formal interim analysis of efficacy and futility will be conducted during the study. 
Interim analyses will be conducted assessing both the primary maternal and neonatal outcomes 
using the primary analytic approach detailed in Section 3.1.1 and 3.1.2. As the maternal and 
neonatal hypotheses are both of equal importance as well as the treatment effect within the high-
risk cohort, the DMC should not recommend early termination for efficacy unless significance is 
observed for both outcomes in all comers and the direction and magnitude of effect in the high-risk 
cohort is consistent with the effect observed in all comers.   
Given the study is extremely well powered for the composite neonatal outcome of death or sepsis, it 
is possible that an effect will be detected much earlier in the study for this outcome (given the high 
frequency of sepsis) than for the maternal outcome.  In such a situation, it is important to continue 
the study to be able to reach a conclusion on whether this prophylactic regimen also benefits 
maternal outcomes, as effective therapeutics for reducing risk of maternal mortality and sepsis are 
sorely needed and this is a maternally administered intervention. Additionally, with respect to the 
neonatal outcome, it is important to assess if the effect is present in sepsis alone vs. the more 
important  death outcome. As such, caution should be taken in terminating this study early. 
However, if efficacy is observed in only a subset of outcomes or subgroups and the study has no 
conditional power to draw conclusions in the remaining outcomes or subgroups, then the DMC may 
still recommend early termination for efficacy. Cut-off p-values for testing for efficacy at this interim 
analysis will be determined based on a correction for multiple comparisons to ensure an overall 
alpha of 0.05. The futility assessment will be based on an analysis of conditional power.  
The details of the timing of the interim analysis as well as the approaches for correcting for 
multiplicity and analyzing conditional power were determined in collaboration with the DMC. The 
single, formal interim analysis of efficacy and futility will be conducted after approximately 70% of 
women have been enrolled and reached primary endpoint. Interim analyses will be conducted using 
the overall study population and the primary analytic approach detailed in Section 9.3. Cut-off p-
values for testing for efficacy at this interim analysis will be determined based on a Bonferroni-type 
correction for multiple comparisons with a nominal α of 0.0001 at the interim analysis and a 
nominal α of 0.0499 for the final analysis (Casella and Berger 2002). Specifically, if the p-values are < 
0.0001 for the treatment versus placebo comparison, then the DSMC may recommend stopping 
enrollment. The DMC can recommend stopping enrollment for futility if the conditional power is less 
than 0.5 at this time. 

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Additionally, the DMC will review the study at periodic intervals, to evaluate whether any safety or 
study progress issues warrant possible study stopping.  These periodic reviews are based on DMC 
reports prepared by the Data coordinating center, which included information on study enrollment 
rates and participant progress through the study, protocol violations, adverse events, and efficacy 
outcomes. The focus of the DMC review is on monitoring participant safety and study 
progress/futility but data on treatment effectiveness will also be presented to frame the DMC 
discussions on safety and futility.   
The DMC will also review the study for study progress and futility, with futility for these analyses 
defined in terms of inability to achieve study enrollment goals.  To effectively complete the study 
within the parameters defined by NICHD and the Global Network Steering Committee, the goal of 
study is to complete enrollment in a 24-month period, and enrollment be completed within 30 
months.  Should the DMC have concern about study progress, the DMC will request from the 
protocol committee an action plan for increasing enrollment that should be delivered to the DMC 
for review within a 1-month period.  Should the DMC consider the plan inadequate or should the 
plan not result in increased enrollment by the next review, the DMC may considered recommending 
to the NICHD closing the study for futility.  
12. CHANGES TO THE ANALYSES PLANNED IN THE PROTOCOL 
13. REFERENCES 
.Abramovici A, Cantu J, Jenkins SM. Tocolytic Therapy for Acute Preterm Labor. Obstet Gynecol Clin 
North Am. 2012; 39:77-87. doi: 10.1016/j.ogc.2011.12.003.  
Anderson RN, Smith BL. Deaths: leading causes for 2001. Natl Vital Stat Rep. 2003;52:1-85.  
Beck S, Wojdyla D, Say L, et al. The worldwide incidence of preterm birth: A systematic review of 
maternal mortality and morbidity. Bull World Health Organ. 2010;88:31-38.  
Blencowe H, Cousens S, Oestergaard MZ, et al. National, regional, and worldwide estimates of 
preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic 
analysis and implications. Lancet. 2012;379:2162-2172. doi:10.1016/S0140-6736(12)60820-4. 
Brock GN, Barnes C, Ramirez JA, Myers J. How to handle mortality when investigating length of 
hospital stay and time to clinical stability. BMC Med Res Methodol. 2011;11:144. Published 2011 Oct 
26. doi:10.1186/1471-2288-11-144  
Goldenberg R, Rouse D. Prevention of Premature Birth. N Engl J Med. 1998;339(5):313-320.  
Hogan JW, Lancaster T. Instrumental variables and inverse probability weighting for causal inference 
from longitudinal observational studies. Stat Methods Med Res. 2004;13:17-48. 
doi:10.1191/0962280204sm351ra. 
Liang KY and Zeger SL. Longitudinal Data Analysis Using Generalized Linear Models. Biometrika. 
1986:73(1): 13-22. 

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March of Dimes, PMNCH, Save the Children, WHO. Born Too Soon: The Global Action Report on 
Preterm Birth. Geneva: World Health Organization; 2012. 
Mathews TJ, Menacker F, MacDorman MF. Infant mortality statistics from the 2002 period: linked 
birth/infant death data set. Natl Vital Stat Rep. 2004;53:1-29 
Maine D, Rosenfield A, McCarthy J, Kamara A, Lucas AO: Safe Motherhood Programs: options and 
issues. New-York: Columbia University; 1991. 
McCormick MC, Richardson DK. Premature infants grow up. N Engl J Med. 2002;346(3):197-198. 
doi:10.1056/NEJM200201173460310. 
McClure EM, Pasha O, Goudar SS, et al; Global Network Investigators. Epidemiology of stillbirth in 
low-middle income countries: a Global Network Study. Acta Obstet Gynecol Scand. 
2011;90(12):1379-85. 
Oestergaard MZ, Inoue M, Yoshida S, Mahanani WR, Gore FM, Cousens S, Lawn JE, Mathers CD; 
United Nations Inter-Agency Group for Child Mortality Estimation and the Child Health Epidemiology 
Reference Group. Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a 
systematic analysis of progress, projections, and priorities. PLoS Med. 2011;8(8):e1001080. 
Schisterman EF, Silver RM, Lesher LL, et al. Preconception low-dose aspirin and pregnancy 
outcomes: Results from the EAGeR randomised trial. Lancet. 2014;384:29-36. doi:10.1016/S0140-
6736(14)60157-4. 
Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to 
adulthood. Lancet. 2008;371:261-269. doi:10.1016/S0140-6736(08)60136-1. 
Valero De Bernabé J, Soriano T, Albaladejo R, et al. Risk factors for low birth weight: A review. Eur J 
Obstet Gynecol Reprod Biol. 2004;116:3-15. doi:10.1016/j.ejogrb.2004.03.007. 
 
 

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Summary of SAP Changes (V.1.0 to V.2.0) 
 
Section 
Changes 
3.1 
Change: Clarify the adjudication process 
If a case requires additional input and cannot be adjudicated locally, then it will 
move to central adjudication where the study PIs will review the participant’s 
information and make a final outcome determination.. 
3.2 
Change: Moved wound infection definition to between Endometritis and Other 
infections since it is not a component of the other infections definition in the 
protocol.  
5.0 
Change: Added word for clarity 
The final determination of HR and PP analysis population membership will be via a 
masked data review prior to final study analyses in order to address any potential 
anomalous cases that may arise in this large of a study population (e.g. 
randomization/treatment of a woman who is discharged prior to delivery due to false 
labor or unresponsiveness to induction).   
9.2  
Definition of Analysis Variables: Changes made to clarify Secondary Outcome 
definitions as the variables were being defined in the analysis datasets. 
Maternal 
sepsis through 
42 days - 
Component 
Change: Clarify the definition of the sepsis diagnosis date for adjudicated cases.  
If the adjudication diagnosis date is before delivery, then it is set to delivery date. If 
the adjudication diagnosis date is more than 3 days after the last unplanned care 
date with adjudication triggers, then it is set to the maximum of delivery date and 
unplanned care visit with adjudication triggers presentation and discharge dates. If 
the algorithm date is 1, 2 or 3 days before delivery and is equal to the first 
unplanned care date then the diagnosis date is set to delivery date. Analysis 
population(s): ITT (all-comer and high risk) 
Maternal 
antibiotic 
therapy after 
randomization 
to 42 days for 
any reason 
Change: Added forms missing from the definition.  
The outcome will be defined as “Yes” if any antibiotic therapy is reported on AZ03 
during initial hospitalization, or on AZ05a, AZ06 or AZ07 during follow-up and prior 
to day 42 and “No” otherwise. 
Time from 
drug 
administration 
until initial 
discharge after 
delivery 
Change: Corrected unit to be days instead of hours 
Time from drug administration until initial discharge after delivery (days) 
Maternal 
admission to 
special care 
units 
Change: Added form missing from the definition.  
The outcome will be defined as “Yes” if there is an AZ03 or AZ07 form where the 
woman is noted as having received care or treatment at an intensive care or 
specialized care unit while at the facility; and “No” otherwise. 
Maternal 
unscheduled 
Change: Clarify definition 
The outcome will be defined as “Yes” if occurrence of unscheduled care after initial 

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visit for care 
delivery discharge is reported on either AZ05a (with a non-missing date of care) or 
on AZ07 form (with a non-missing exact or estimated date of care); and “No” 
otherwise. 
Neonatal 
Other 
Infections 
Change: Revised definition to be more precise and removed adjudication text.  
The event will be defined as “Yes” if any infection is reported that does not qualify 
for sepsis prior to day 28 and “No” otherwise.  Other neonatal infections include 
eye infection with swelling and drainage, skin infection with 10 or more pustules or 
bullae, omphalitis, urinary tract infection, pyelonephritis or kidney infection, 
pneumonia or lung infection, meningitis, other infection documented in clinical 
record or respiratory rate ≥ 60. The outcome will only be missing for infants that are 
lost to follow-up prior to completion of a Day 7 visit and neonatal deaths prior to 7 
days that do not quality for sepsis or other infections.  
 
Neonatal 
admission to 
special care 
units 
Change: Added form missing from the definition.  
The outcome will be defined as “Yes” if there is an AZ04 or AZ08 form where the 
infant is noted as having received care or treatment at an intensive care or 
specialized care unit while at the facility; and “No” otherwise. 
Neonatal 
Unscheduled 
Clinical or ER 
Visit 
Change: Clarify definition. 
The outcome will be defined as “Yes” if occurrence of unscheduled care after initial 
delivery discharge is reported on either AZ05b (with a non-missing date of care) or 
there is an AZ08 form (with a non-missing exact or estimated date of care); and 
“No” otherwise. 
9.3  
Change: Added specific exploratory analysis. 
Kaplan-Meier survival curves will be fit to the data in order to get cumulative 
incidence curves by treatment group of the timing of the first occurrence of 
maternal death or sepsis and intrapartum/neonatal death or sepsis.