title: 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.
abstract: BACKGROUND
  Despite the global burden of morbidity and mortality associated with preterm birth, little evidence is available for use of antenatal corticosteroids and tocolytic drugs in preterm births in low-income and middle-income countries. We analysed data from the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS) to assess coverage for these interventions in preterm deliveries.
  
  
  METHODS
  WHOMCS is a facility-based, cross-sectional survey database of birth outcomes in 359 facilities in 29 countries, with data collected prospectively from May 1, 2010, to Dec 31, 2011. For this analysis, we included deliveries after 22 weeks' gestation and we excluded births that occurred outside a facility or quicker than 3 h after arrival. We calculated use of antenatal corticosteroids in women who gave birth between 26 and 34 weeks' gestation, when antenatal corticosteroids are known to be most beneficial. We also calculated use in women at 22-25 weeks' and 34-36 weeks' gestation. We assessed tocolytic drug use, with and without antenatal corticosteroids, in spontaneous, uncomplicated preterm deliveries at 26-34 weeks' gestation.
  
  
  RESULTS
  Of 303,842 recorded deliveries after 22 weeks' gestation, 17,705 (6%) were preterm. 3900 (52%) of 7547 women who gave birth at 26-34 weeks' gestation, 94 (19%) of 497 women who gave birth at 22-25 weeks' gestation, and 2276 (24%) of 9661 women who gave birth at 35-36 weeks' gestation received antenatal corticosteroids. Rates of antenatal corticosteroid use varied between countries (median 54%, range 16-91%; IQR 30-68%). Of 4677 women who were potentially eligible for tocolysis drugs, 1276 (27%) were treated with bed rest or hydration and 2248 (48%) received no treatment. β-agonists alone (n=346, 7%) were the most frequently used tocolytic drug. Only 848 (18%) of potentially eligible women received both a tocolytic drug and antenatal corticosteroids.
  
  
  CONCLUSIONS
  Use of interventions was generally poor, despite evidence for their benefit for newborn babies. A substantial proportion of antenatal corticosteroid use occurred at gestational ages at which benefit is controversial, and use of less effective or potentially harmful tocolytic drugs was common. Implementation research and contextualised health policies are needed to improve drug availability and increase compliance with best obstetric practice.
  
  
  BACKGROUND
  UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.
authors.affiliation: School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Crawley, WA, Australia; UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland. Electronic address: vogeljo@who.int.
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Vogel
authors.affiliation: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland; Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
authors.forename: João Paulo
authors.initials: JP
authors.lastname: Souza
authors.affiliation: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland.
authors.forename: A Metin
authors.initials: AM
authors.lastname: Gülmezoglu
authors.affiliation: Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
authors.forename: Rintaro
authors.initials: R
authors.lastname: Mori
authors.affiliation: Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
authors.forename: Pisake
authors.initials: P
authors.lastname: Lumbiganon
authors.affiliation: Department of Obstetrics and Gynaecology, School of Medicine, College of Health Science, University of Nairobi, Nairobi, Kenya.
authors.forename: Zahida
authors.initials: Z
authors.lastname: Qureshi
authors.affiliation: Centro Rosarino de Estudios Perinatales, Rosario, Argentina.
authors.forename: Guillermo
authors.initials: G
authors.lastname: Carroli
authors.affiliation: Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.
authors.forename: Malinee
authors.initials: M
authors.lastname: Laopaiboon
authors.affiliation: University of Ibadan, Ibadan, Nigeria.
authors.forename: Bukola
authors.initials: B
authors.lastname: Fawole
authors.affiliation: Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
authors.forename: Togoobaatar
authors.initials: T
authors.lastname: Ganchimeg
authors.affiliation: Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Jun
authors.initials: J
authors.lastname: Zhang
authors.affiliation: Department of Obstetrics, São Paulo Federal University, São Paulo, Brazil; Brazilian Cochrane Centre, São Paulo, Brazil.
authors.forename: Maria Regina
authors.initials: MR
authors.lastname: Torloni
authors.affiliation: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland; Johns Hopkins Bloomberg School of Public Health, Department of Population, Family and Reproductive Health, Baltimore, MD, USA.
authors.forename: Meghan
authors.initials: M
authors.lastname: Bohren
authors.affiliation: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland.
authors.forename: Marleen
authors.initials: M
authors.lastname: Temmerman
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D005260:Female; D005865:Gestational Age; D006801:Humans; D007231:Infant, Newborn; D008429:Maternal Welfare; D011247:Pregnancy; D011256:Pregnancy Outcome; D047928:Premature Birth / Q000453:epidemiology / Q000517:prevention & control*; D011295:Prenatal Care / Q000379:methods*; D018570:Risk Assessment; D015149:Tocolytic Agents / Q000008:administration & dosage*; D016896:Treatment Outcome; D014944:World Health Organization; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones; D015149:Tocolytic Agents