Antenatal steroids in preterm labour for the prevention of neonatal deaths due to complications of preterm birth

Abstract

Background In high-income countries, administration of antenatal steroids is standard care for women with anticipated preterm labour. However, although >1 million deaths due to preterm birth occur annually, antenatal steroids are not routine practice in low-income countries where most of these deaths occur.Objectives To review the evidence for and estimate the effect on cause-specific neonatal mortality of administration of antenatal steroids to women with anticipated preterm labour, with additional analysis for the effect in low- and middle-income countries.Methods We conducted systematic reviews using standardized abstraction forms. Quality of evidence was assessed using an adapted GRADE approach. Existing meta-analyses were reviewed for relevance to low/middle-income countries, and new meta-analysis was performed.Results We identified 44 studies, including 18 randomised control trials (RCTs) (14 in high-income countries) in a Cochrane meta-analysis, which suggested that antenatal steroids decrease neonatal mortality among preterm infants (<36 weeks gestation) by 31% [relative risk (RR) = 0.69; 95% confidence interval (CI) 0.58–0.81]. Our new meta-analysis of four RCTs from middle-income countries suggests 53% mortality reduction (RR = 0.47; 95% CI 0.35–0.64) and 37% morbidity reduction (RR = 0.63; 95% CI 0.49–0.81). Observational study mortality data were consistent. The control group in these equivalent studies was routine care (ventilation and, in many cases, surfactant). In low-income countries, many preterm babies currently receive little or no medical care. It is plausible that antenatal steroids may be of even greater effect when tested in these settings.Conclusions Based on high-grade evidence, antenatal steroid therapy is very effective in preventing neonatal mortality and morbidity, yet remains at low coverage in low/middle-income countries. If fully scaled up, this intervention could save up to 500 000 neonatal lives annually.

The smallest of the small: short-term outcomes of profoundly growth restricted and profoundly low birth weight preterm infants

“…12,13 Our data and previous CPQCC data suggest that the benefit seen in younger and smaller infants is similar to that seen in their larger and more mature peers. 6 Data on the effect of cesarean section of survival of preterm infants are contradictory.…”

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

“…19 The effects of antenatal steroids in decreasing neonatal mortality among preterm infants are also evident in middle-income countries, with an estimated reduction of 53%. 20 The frequency of Cesarean section in extremely preterm infants was also lower in our cohort than in the NICHD Neonatal Research Network: 11% vs 24% at 23 weeks, 36% vs 60% at 24 weeks, 54% vs 65% at 25 weeks and 64% vs 68% at 26 weeks. 13 The impact of surgical delivery on mortality in very low birth weight infants is confounded by multiple variables: the maternal risk factors for neonatal morbidity and mortality, the decision of the perinatal team to invest in infants' survival and the different strata of birth weight or gestational age used to analyze the outcome.…”

Stillbirths: how can health systems deliver for mothers and babies?

“…Costs of visits were estimated to be 9% higher in regions with 80-95% coverage, and 24% higher in regions with 95-99% coverage, than were visits in regions with less than 80% coverage. Cost assumptions are detailed in webappendix pp [3][4][5][6][7][8][9][10][11][12][13][14][15] Eff ect estimates refer to the reduction in deaths due to a specifi c cause as a result of intervention-eg, 0·41 for stillbirths due to neural tube defects means that 41% of stillbirths due to neural tube defects could be averted with introduction of folic acid supplementation or fortifi cation. Postnatal interventions are not included so the estimates do not represent the full eff ect on neonatal deaths.…”