Use of Antenatal Corticosteroids and Tocolytic Drugs in Preterm Births in 29 Countries: An Analysis of the WHO Multicountry Survey on Maternal and Newborn Health EDITORIAL COMMENT

With more than 15 million infants born preterm annually, preterm birth is the largest cause of death among newborns and the second among children younger than 5 years. Antenatal corticosteroids can improve neonatal outcomes when given at 26 to 34 weeks plus 6 days' gestation, even if given less than 24 hours before delivery. The use of antenatal corticosteroids outside this gestational age range is controversial, but they can be beneficial at 22 to 26 weeks. Tocolytic drugs inhibit labor progression, but their use alone does not reduce perinatal mortality. No reports have been published on patterns of tocolytic drug use in preterm labor in low- and middle-income countries. This analysis of the World Health Organization Multicountry Survey of Maternal and Newborn Health data set for facility-based deliveries in 29 countries was performed to assess patterns of use of antenatal corticosteroids in preterm deliveries and tocolytic drugs in spontaneous preterm deliveries. This study was a cross-sectional, facility-based survey of deliveries (2010-2011) aimed at characterizing severe maternal, perinatal, and neonatal morbidity for a worldwide network of health facilities. A global sample of facilities in Africa, Asia, Latin America, and the Middle East was obtained. Study participants were all women who gave birth in participating facilities and women with a severe maternal outcome associated with pregnancy, childbirth, or puerperium. Data were obtained prospectively from time of presentation until discharge or 7 days postpartum, Overall, 359 facilities in 29 countries participated, and data from 314,623 women were recorded. Information was obtained on maternal sociodemographic, medical, and obstetric characteristics and outcomes for mothers and newborn babies. The use of antenatal corticosteroids in preterm births was recorded, although the type, timing, number of doses, and dosing schedule were not. The use of 5 classes of tocolytic drugs for preterm labor was also recorded: -agonists, nonsteroidal anti-inflammatory drugs, and cyclooxygenase inhibitors, calcium-channel blockers, oxytocin antagonists, and magnesium sulfate. Use of bed rest, hydration, or no treatment for preterm labor was recorded, as well. Pregnancies at 22 weeks or more were included. Preterm deliveries were categorized as 22 to 25, 26 to 34, and 35 to 36 weeks. The use of antenatal corticosteroids was calculated in women who gave birth at 26 to 34 weeks when antenatal corticosteroids are most beneficial, as well as at 22 to 25 weeks and 34 to 36 weeks. Tocolytic drug use was assessed, with and without use of antenatal corticosteroids, in spontaneous, uncomplicated preterm deliveries at 26 to 34 weeks. Other outcomes included the rate of documented antenatal corticosteroid use overall and, for each country, identification of women who had spontaneous preterm labor at 26 to 34 weeks and who did not have a major contraindication to tocolysis and use of tocolysis treatments, with and without antenatal corticosteroids, in these women. Of 303,842 women included, 17,705 (6%) gave birth preterm across all facilities. The 7547 women who gave birth at 26 to 34 weeks accounted for 2.5% of all deliveries. Of these, 4906 women (65%) had a spontaneous preterm birth, of which 4677 (95%) were spontaneous preterm births without a major contraindication to tocolysis. Of the women who delivered at 26 to 34 weeks, 52% received antenatal corticosteroids. When stratified by spontaneous preterm birth or provider-initiated preterm birth (induced labor or a prelabor cesarean delivery [CD]), antenatal corticosteroid use for women at 26 to 34 weeks was similar ((2) = 0.62). When analyzed for countries, median antenatal corticosteroid coverage was 54% (range, 16%-91%; interquartile range, 30%-68%). The adjusted odds of receiving antenatal corticosteroids were significantly raised in nulliparous women and in intrapartum CDs and prelabor CDs. Among the 4677 women with uncomplicated, spontaneous preterm labor who were eligible for tocolytic treatment, almost half received no treatment, and a quarter received nondrug treatments. The most frequently used drugs for tocolysis were -agonists and calcium-channel blockers. Only 848 women (18%) in this group received a tocolytic drug combined with antenatal corticosteroids. Most women received neither a tocolytic drug nor antenatal corticosteroids, or antenatal corticosteroids without a tocolysis drug; and a few received tocolysis without concurrent antenatal corticosteroids. At the country level, the median rate of tocolytic drug use in combination with antenatal corticosteroids was 19% (range, 0%-100%). Antenatal corticosteroids and tocolytic drugs were substantially underused in women in whom they would have been beneficial. If recognition of preterm labor is to be followed by early antenatal corticosteroids, with or without tocolytic drugs, then drugs should be readily available at the time and place of presentation. Inclusion of dexamethasone or betamethasone or both on national essential medicine lists could improve outcomes for preterm babies. Despite the evidence for effectiveness of antenatal corticosteroids and tocolytic drugs in preterm deliveries, their use was highly variable and often poor. The use of ineffective, less effective, or potentially harmful treatments for tocolysis was widespread in this study. Implementation research and revised health policies are needed to improve drug availability and compliance with best obstetric practices.