The Comment 1 by Kishwar Azad and Anthony Costello opposing scale-up of antenatal corticosteroids misdirects the discussion of this topic towards speculation about differences in low-income settings. Our experience in Malawi provides a concrete example of the rapid scaling up of antenatal corticosteroid treatment with dexamethasone.
In Bwaila Maternity Hospital, Lilongwe, that has more than 15 000 deliveries annually with more than 2900 preterm, we increased targeted coverage of antenatal corticosteroids from 8% to 80% in 16 weeks in women at risk of preterm delivery from 24 to 34 weeks’ gestation. After this pilot study, we began programmes in three other hospitals, reaching 59—83% coverage from a baseline of 1—6% within 6 weeks. This intervention has thus far been associated with a drop in preterm neonatal mortality contribution from 60% to 24% at 0—6 days of age. Although this intervention was not done as part of a trial, and focuses only on quality improvement, we noted no increase in the rate of maternal or neonatal infections.