title: A multi-faceted intervention including antenatal corticosteroids to reduce neonatal mortality associated with preterm birth: a case study from the Guatemalan Western Highlands.
abstract: BACKGROUND
  The Global Network for Women's and Children's Health Research undertook a cluster-randomized trial to assess the impact of a multi-faceted intervention to identify women at high-risk of preterm birth at all levels of care, to administer corticosteroids to women and refer for facility delivery compared with standard care. Of the seven sites that participated in the ACT trial, only two sites had statistically significant reductions in the neonatal mortality among the target group of <5th percentile infants, and of the two, Guatemala's improvement in neonatal mortality was by far the largest.
  
  
  METHODS
  We used data available from the ACT trial as well as pretrial data in an attempt to understand why neonatal mortality may have decreased in the intervention clusters in <5(th) percentile infants in Chimaltenango, Guatemala. The intervention and control clusters were compared in regards to ACS use, the various types of medical care, outcomes in facility and community births and among births in various birth weight categories.
  
  
  RESULTS
  Neonatal mortality decreased to a greater extent in the intervention compared to the control clusters in the <5(th) percentile infants in Guatemala during the ACT Trial. ACS use for the <5(th) percentile infants in the intervention clusters was 49.1 % compared to 13.8 % in the control clusters. Many measures of the quality of obstetric and neonatal care improved to a greater extent in the intervention compared to the control clusters during the trial. Births in facilities and births weighing 1500 to 2500 g had the greatest reduction in neonatal mortality.
  
  
  CONCLUSIONS
  The combination of improved care and greater ACS use may potentially account for the observed difference in neonatal mortality between the intervention and control clusters.
  
  
  BACKGROUND
  Clinicaltrials.gov: NCT01084096 .
authors.affiliation: FANCAP, Guatemala City, Guatemala. agarces@fancap.org.
authors.forename: Ana
authors.initials: A
authors.lastname: Garces
authors.affiliation: RTI International, Durham, NC, USA.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: McClure
authors.affiliation: FANCAP, Guatemala City, Guatemala.
authors.forename: Lester
authors.initials: L
authors.lastname: Figueroa
authors.affiliation: FANCAP, Guatemala City, Guatemala.
authors.forename: Sayury
authors.initials: S
authors.lastname: Pineda
authors.affiliation: University of Colorado School of Medicine, Denver, CO, USA.
authors.forename: K Michael
authors.initials: KM
authors.lastname: Hambidge
authors.affiliation: University of Colorado School of Medicine, Denver, CO, USA.
authors.forename: Nancy F
authors.initials: NF
authors.lastname: Krebs
authors.affiliation: RTI International, Durham, NC, USA.
authors.forename: Vanessa R
authors.initials: VR
authors.lastname: Thorsten
authors.affiliation: RTI International, Durham, NC, USA.
authors.forename: Dennis D
authors.initials: DD
authors.lastname: Wallace
authors.affiliation: IECS, Buenos Aires, Argentina.
authors.forename: Fernando
authors.initials: F
authors.lastname: Althabe
authors.affiliation: University of Columbia School of Medicine, New York, NY, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Goldenberg
mesh_terms: D000293:Adolescent; D000328:Adult; D001724:Birth Weight; D036861:Delivery, Obstetric / Q000379:methods; D003906:Developing Countries; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use*; D006166:Guatemala / Q000453:epidemiology; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D008423:Maternal Age; D011247:Pregnancy; D047928:Premature Birth / Q000517:prevention & control*; D011295:Prenatal Care / Q000379:methods*; D055815:Young Adult
chemical_list: D005938:Glucocorticoids