The World Health Organization Antenatal CorTicosteroids for Improving Outcomes in preterm Newborns (ACTION-III) Trial: study protocol for a multi-country, multi-centre, double-blind, three-arm, placebo-controlled, individually randomized trial of antenatal corticosteroids for women at high probability of late preterm birth in hospitals in low- resource countries
Authors:   WHO ACTION Trials Collaborators, Adegboyega Temitope Adesiji , Adejuyigbe Ebunoluwa Aderonke , Adesina Olubukola Adeponle , Adeyemi Babalola , Ahmed Salahuddin , Akinkunmi Francis , Aluvaala Jalemba , Anyabolu Henry , Ariff Shabina , Arya Sugandha , Awowole Ibraheem , Ayede Adejumoke Idowu , Babar Neelofur , Bachani Sumitra , Bahl Rajiv , Baqui Abdullah H. , Chellani Harish , Chowdhury Saleha Begum , Coppola Lynn M. , Cousens Simon , Debata Pradeep K. , de Costa Ayesha , Dhaded Sangappa M. , Donimath Kasturi V. , Falade Adegoke Gbadegesin , Goudar Shivaprasad S. , Gupta Shuchita , Gwako George N. , Irinyenikan Theresa Azonima , Isah Dennis Anthony , Jabeen Nigar , Javed Arshia , Joseph Naima T. , Khanam Rasheda , Kinuthia John , Kuti Oluwafemi , Lavin Tina , Laving Ahmed R. , Maranna Sandhya , Minckas Nicole , Mittal Pratima , Mohan Diwakar , Nausheen Sidrah , Nguyen My Huong , Oladapo Olufemi T. , Olutekunbi Olanike Abosede , Oluwafemi Rosena Olubanke , Osoti Alfred , Pujar Yeshita V. , Qureshi Zahida P. , Rao Suman P. N. , Sarrassat Sophie , Shahed M. A. , Shahidullah Mohammod , Sheikh Lumaan , Somannavar Manjunath S. , Soofi Sajid , Suri Jyotsna , Vernekar Sunil S. , Vogel Joshua P. , Wadhwa Nitya , Wari Prakash K. , Were Fred , Wylie Blair J. 
Published: April 2024

Abstract
Background
Preterm birth complications are the leading cause of newborn and under-5 mortality. Over 85% of all preterm births occur in the late preterm period, i.e. between 34 and < 37 weeks of gestation. Antenatal corticosteroids (ACS) prevent mortality and respiratory morbidity when administered to women at high risk of an early preterm birth, i.e. < 34 weeks’ gestation. However, the benefits and risks of ACS in the late preterm period are less clear; both guidelines and practices vary between settings. Emerging evidence suggests that the benefits of ACS may be achievable at lower doses than presently used. This trial aims to determine the efficacy and safety of two ACS regimens compared to placebo, when given to women with a high probability of late preterm birth, in hospitals in low-resource countries.

Methods
WHO ACTION III trial is a parallel-group, three-arm, individually randomized, double-blind, placebo-controlled trial of two ACS regimens: dexamethasone phosphate 4 × 6 mg q12h or betamethasone phosphate 4 × 2 mg q 12 h. The trial is being conducted across seven sites in five countries—Bangladesh, India, Kenya, Nigeria, and Pakistan. Eligible women are those with a gestational age between 34 weeks 0 days and 36 weeks 5 days, who have a high probability of preterm birth between 12 h and 7 days (up to 36 weeks 6 days gestation). The primary outcome is a composite of stillbirth or neonatal death within 72 h of birth or use of newborn respiratory support within 72 h of birth or prior to discharge from hospital, whichever is earlier. Secondary outcomes include safety and health utilization measures for both women and newborns. The sample size is 13,500 women.

Discussion
This trial will evaluate the benefits and possible harms of ACS when used in women likely to have a late preterm birth. It will also evaluate a lower-dose ACS regimen based on literature from pharmacokinetic studies. The results of this trial will provide robust critical evidence on the safe and appropriate use of ACS in the late preterm period internationally.

Trial registration
ISRCTN11434567. Registered on 7 June 2021.