title: Use of antenatal corticosteroids at health facilities and communities in low-and-middle income countries.
abstract: BACKGROUND
  Antenatal corticosteroids (ACS) for women at high risk of preterm birth is an effective intervention to reduce neonatal mortality among preterm babies delivered in hospital settings, but has not been widely used in low-middle resource settings. We sought to assess the rates of ACS use at all levels of health care in low and middle income countries (LMIC).
  
  
  METHODS
  We assessed rates of ACS in 7 sites in 6 LMIC participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Global Network for Women and Children's Health Research Antenatal Corticosteroids Trial (ACT), a cluster-randomized trial to assess the feasibility, effectiveness, and safety of a multifaceted intervention designed to increase the use of ACS. We conducted this analysis using data from the control clusters, which did not receive any components of the intervention and intended to follow usual care. We included women who delivered an infant with a birth weight <5th percentile, a proxy for preterm birth, and were enrolled in the Maternal Newborn Health (MNH) Registry between October 2011 and March 2014 in all clusters. A survey of the site investigators regarding existing policies on ACS in health facilities and for health workers in the community was part of pre-trial activities.
  
  
  RESULTS
  Overall, of 51,523 women delivered in control clusters across all sites, the percentage of <5th percentile babies ranged from 3.5 % in Kenya to 10.7 % in Pakistan. There was variation among the sites in the use of ACS at all hospitals and among those hospitals having cesarean section and neonatal care capabilities (bag and mask and oxygen or mechanical ventilation). Rates of ACS use for <5th percentile babies in all hospitals ranged from 3.8 % in the Kenya sites to 44.5 % in the Argentina site, and in hospitals with cesarean section and neonatal care capabilities from 0 % in Zambia to 43.5 % in Argentina. ACS were rarely used in clinic or home deliveries at any site. Guidelines for ACS use at all levels of the health system were available for most of the sites.
  
  
  CONCLUSIONS
  Our study reports an overall low utilization of ACS among mothers of <5th percentile infants in hospital and clinic deliveries in LMIC.
  
  
  BACKGROUND
  clinicaltrials.gov ( NCT01084096 ).
authors.affiliation: Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina. mberrueta@iecs.org.ar.
authors.forename: Mabel
authors.initials: M
authors.lastname: Berrueta
authors.affiliation: RTI International, Durham, NC, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hemingway-Foday
authors.affiliation: RTI International, Durham, NC, USA.
authors.forename: Vanessa R
authors.initials: VR
authors.lastname: Thorsten
authors.affiliation: Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Goldenberg
authors.affiliation: University of Alabama at Birmingham, Birmingham, AL, USA.
authors.forename: Waldemar A
authors.initials: WA
authors.lastname: Carlo
authors.affiliation: Fundación para la Alimentación y Nutrición de Centro América y Panamá, Guatemala City, Guatemala.
authors.forename: Ana
authors.initials: A
authors.lastname: Garces
authors.affiliation: Lata Medical Research Foundation, Indira Gandhi Government Medical College, Nagpur, India.
authors.forename: Archana
authors.initials: A
authors.lastname: Patel
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
authors.forename: Sarah
authors.initials: S
authors.lastname: Saleem
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
authors.forename: Omrana
authors.initials: O
authors.lastname: Pasha
authors.affiliation: University Teaching Hospital, Lusaka, Zambia.
authors.forename: Elwyn
authors.initials: E
authors.lastname: Chomba
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Hibberd
authors.affiliation: University of Colorado School of Medicine, Denver, CO, USA.
authors.forename: Nancy F
authors.initials: NF
authors.lastname: Krebs
authors.affiliation: KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India.
authors.forename: Shivaprasad
authors.initials: S
authors.lastname: Goudar
authors.affiliation: Christiana Health Care, Newark, DE, USA.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Derman
authors.affiliation: Moi University School of Medicine, Eldoret, Kenya.
authors.forename: Fabian
authors.initials: F
authors.lastname: Esamai
authors.affiliation: School of Medicine, Indiana University, Indianapolis, IN, USA.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Liechty
authors.affiliation: RTI International, Durham, NC, USA.
authors.forename: Janet L
authors.initials: JL
authors.lastname: Moore
authors.affiliation: RTI International, Durham, NC, USA.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: McClure
authors.affiliation: Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
authors.forename: Marion
authors.initials: M
authors.lastname: Koso-Thomas
authors.affiliation: Tulane School of Public Health & Tropical Medicine, New Orleans, LA, USA.
authors.forename: Pierre M
authors.initials: PM
authors.lastname: Buekens
authors.affiliation: Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.
authors.forename: José M
authors.initials: JM
authors.lastname: Belizán
authors.affiliation: Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.
authors.forename: Fernando
authors.initials: F
authors.lastname: Althabe
mesh_terms: D001724:Birth Weight; D003151:Community Health Centers; D003906:Developing Countries; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage* / Q000627:therapeutic use; D006268:Health Facilities; D006801:Humans; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D007752:Obstetric Labor, Premature / Q000517:prevention & control; D011247:Pregnancy; D011295:Prenatal Care / Q000379:methods / Q000706:statistics & numerical data*
chemical_list: D005938:Glucocorticoids