In the March 2014 Issue of The Lancet Global Health, Kishwar Azad, Director of the Perinatal Care Project at the Diabetic Association of Bangladesh, and Anthony Costello, Director of the UCL Institute for Global Health, suggest the use of extreme caution in the 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 women in low-income countries.
Maternal and newborn health experts and members from the Antenatal Corticosteroids Technical Reference Team for the UN Commission on Life Saving Commodities published a series of letters in response to Kishwar and Costello.
Read the letters, shared this week on The Lancet Global Health:
- In their Comment, 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 Trial 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. [Read more]
- 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. [Read more]
- We support the call for more research, especially on how to reach the poorest women and how to increase long-term health for both women and their babies. In the meantime, the evidence strongly supports giving a single, short course of corticosteroids to women at risk of preterm birth in hospitals everywhere, not just in high-income countries. [Read more]
Caroline Crowther and Julie Brown:
- Kishwar and Costello emphasise maternal sepsis as a concern but cite only one trial in which dexamethasone resulted in a significant increase in fever that required antibiotic treatment compared with controls (relative risk [RR] 2·05, 95% CI 1·14–3·69; 118 women). We suggest that this finding alone does not reflect a balanced assessment of the paucity of evidence available. [Read more]
Author’s Reply: Kishwar Azad, Anthony Costello
- We agree with many of the correspondents’ points. First, we concur that antenatal corticosteroid treatment can reduce respiratory distress in infants born at less than 34 weeks’ gestation. Second, we welcome the rapid scale-up of its use in hospitals in Malawi, as described by Stephen Kaliti, and look forward to the published assessment of its effect on mortality in preterm infants. Third, we agree that more research is needed to explore the best methods for scale-up in hospitals and to assess the risks and benefits to patients through community studies in low-income regions. [Read more]
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