Antenatal corticosteroids to reduce preterm deaths in low-income settings
Authors: Fernando Althabe, José M Belizán, Pierre Buekens, Elizabeth M McClure, Marion Koso-thomas
Journal: The Lancet Global Health (2014)

In their Comment (April issue),1Azad K Costello A Extreme caution is needed before scale-up of antenatal corticosteroids to reduce preterm deaths in low-income settings.Lancet Glob Health. 2014; 2: e191-e192Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar Kishwar Azad and Anthony Costello raise questions that should be answered before antenatal corticosteroid treatment is scaled up to reduce preterm deaths in low-income countries. We share their concerns about the unknown overall effect of this treatment on mortality and potential safety issues in the mother. To answer these questions, we have initiated the Antenatal Corticosteroids Trial2Althabe F Belizán JM Mazzoni A et al.Antenatal corticosteroids trial in preterm births to increase neonatal survival in developing countries: study protocol.Reprod Health. 2012; 9: 22Crossref PubMed Scopus (32) Google Scholar to assess whether or not a multifaceted intervention to increase the use of antenatal corticosteroids reduces neonatal mortality at 28 days of age, and maternal morbidity due to infections. Enrolment has been completed and data from more than 90 000 births have been collected. We disagree with Azad and Costello's comment about the effect of antenatal corticosteroid treatment on respiratory distress in infants at 34 weeks' gestation. This statement is based on a subgroup analysis from a systematic review.3Roberts D Dalziel SR Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth.Cochrane Database Syst Rev. 2006; 3 (CD004454.)Crossref Scopus (1196) Google Scholar However, the same review presents data showing a decreased risk of respiratory distress syndrome in infants with first dose of corticosteroids administered to mothers at 33–35 weeks' gestation (relative risk [RR] 0·53, 95% CI 0·31–0·91), and a non-significant decrease in the risk of respiratory distress in infants (0·61, 0·11–3·26) with first dose at 35–37 weeks' gestation. The findings suggest a reduction in respiratory distress syndrome is present according to gestational age at first delivery of corticosteroids.3Roberts D Dalziel SR Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth.Cochrane Database Syst Rev. 2006; 3 (CD004454.)Crossref Scopus (1196) Google Scholar Prevention of respiratory distress syndrome in infants born at 33–36 weeks' gestation without access to specialised high-quality level 2 care might create a substantial health-care burden in low-income countries. The Antenatal Corticosteroids Trial2Althabe F Belizán JM Mazzoni A et al.Antenatal corticosteroids trial in preterm births to increase neonatal survival in developing countries: study protocol.Reprod Health. 2012; 9: 22Crossref PubMed Scopus (32) Google Scholar will assess the administration of steroids to mothers up to 36 weeks' gestation. Data from this trial will be available in the second half of 2014. We hope that several of the concerns expressed in the Comment by Azad and Costello will be addressed. We declare that we have no competing interests. Extreme caution is needed before scale-up of antenatal corticosteroids to reduce preterm deaths in low-income settingsThe great American epidemiologist Bill Silverman taught us that the road to hell is paved with good intentions. From 1942, during a 12-year period, more than 10 000 infants were blinded through retinopathy of prematurity because paediatricians recommended a minor increase in the concentration of supplemental oxygen for preterm infants in incubators.1 Later, "untold thousands of premature infants succumbed in the first few days of life because incubator temperatures were set slightly too low (to avoid overheating)". Full-Text PDF Open AccessContext and collaborationThe last 25 years of the 20th century were traumatic ones for Timor-Leste. Invaded by Indonesia in 1975, the country endured a long and bloody battle against occupation, during which 100 000 people were estimated to have been killed, and torture and displacement were widespread. A referendum in 1999, which revealed overwhelming support for independence, also came at a cost—pro-Indonesia militia ran amok and it took an international peacekeeping force, followed by a UN mission, to restore calm. Full-Text PDF Open AccessEffects of recurrent violence on post-traumatic stress disorder and severe distress in conflict-affected Timor-Leste: a 6-year longitudinal studyRecurrent violence resulted in a major increase in post-traumatic stress disorder and severe distress in a community previously exposed to mass conflict. Poverty, ongoing community tensions, and persisting feelings of injustice contributed to mental disorders. The findings underscore the importance of preventing recurrent violence, alleviating poverty, and addressing injustices in countries emerging from conflict. Full-Text PDF Open AccessCalling on Europe to support operational research in low-income and middle-income countriesOperational research in public health is the investigation of strategies, interventions, instruments, or knowledge that can enhance the quality, coverage, effectiveness, or performance of health systems, health services, or disease control programmes.1 By showing what works and what does not in various contexts, operational research can provide evidence to help policy makers to adapt health interventions and services for maximum public health benefit.2 Full-Text PDF Open Access