Antenatal corticosteroids to reduce preterm deaths in low-income settings

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Kishwar Azad and Anthony Costello 1 suggest the use of extreme caution in scaling up of antenatal corticosteroid treatment in low-income settings. They raise three important questions with respect to the efficacy, safety, and the appropriate gestational age at which to give corticosteroids to patients in low-income countries. 

Firstly, in terms of efficacy, there is high-quality evidence on the benefits of antenatal corticosteroids for lung maturation in utero. A large decrease in neonatal mortality was reported in trials in four middle-income countries, including those in Africa and the Middle East (relative risk [RR] 0·47, 95% CI 0·35—0·64), compared with 14 studies in high-income countries (0·79, 0·65—0·96). 2,Antenatal corticosteroids actually reduced the need for level 2 care, including mechanical ventilation or continuous positive airway pressure in four studies (0·69, 0·53—0·90) and intensive care in two studies (0·80, 0·65—0·99) suggesting that, in regions where mechanical ventilation is not available, substantial benefits could be expected.2, 3 We agree that more research is needed but in view of the biological basis for the effect of antenatal corticosteroids on infant mortality, it is extremely unlikely, statistically, that antenatal corticosteroids would be shown not to work in African or Asian babies. 

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