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Countries have put in place some elements necessary for safe and effective antenatal corticosteroid (ACS) use, but significant challenges remain including: ensuring accurate gestational age determination, establishing clear treatment guidelines, strengthening provider capacity, incorporating obstetric indications for ACS use in national essential medicines lists, and collecting and using ACS-related data in the HMIS. Most importantly, the quality of maternal and newborn care, including specialized newborn care, needs improvement to ensure a strong foundation for the safe and effective use of ACS. Background: Every year approximately 15 million babies are born prematurely and nearly 1 million die due to preterm birth complications. Evidence shows that antenatal corticosteroids (ACS) can be used to improve preterm birth outcomes in particular clinical settings. We conducted a policy and implementation landscape analysis of ACS use for women at risk of imminent preterm birth in 7 low-income countries. Methods: A study framework and situation analysis tool were developed based on the World Health Organization (WHO) recommendation for ACS use among women at risk of preterm birth. The study was conducted in the Democratic Republic of the Congo, Ethiopia, Malawi, Nigeria, Sierra Leone, Tanzania, and Uganda. Primary data were collected through key informant interviews. Secondary data were gathered from publicly available sources, a survey of health management information system indicators, and demographic data from the Every Preemie—SCALE country profiles for preterm and low birth weight prevention and care. Results: All 7 countries are using ACS for women at risk of imminent preterm birth. The majority of countries include language on ACS use in clinical protocols or standard treatment guidelines; however, none include language on accurately measuring gestational age. For 2 of the 5 countries with national standards for ACS use, the upper gestational age limit for ACS use exceeded the WHO recommendation of 34 weeks. There are gaps in national guidance on how to determine if a woman is at risk of imminent preterm birth. Few countries include guidance that indicates ACS is contraindicated in the presence of infection. The majority of countries reported that facilities providing ACS meet comprehensive emergency obstetric and newborn care standards, and all countries reported the availability of some form of special newborn care or neonatal intensive care units at facilities providing ACS. Conclusions: Countries recognize challenges to access to high-quality maternal and newborn care that fulfill clinical care preconditions required for safe and effective ACS use. Key informants recommended support for clinical guidelines and provider training on ACS use, inclusion of obstetric indications for dexamethasone and betamethasone in national essential medicine lists, collecting and using ACS-related data, and improving the quality of maternal and newborn care, including specialized newborn care.
The study team used a framework and situation analysis tool to focus on public-sector services in 7 countries for this landscape analysis. We included the following UNCoLSC Pathfinder countries in the study: the DRC, Ethiopia, Malawi, Nigeria, Sierra Leone, Tanzania, and Uganda. However, Senegal was omitted from the study due to a lack of response from in-country stakeholders. We used primary qualitative research methods to collect information about ACS use through key informant interviews. Secondary quantitative data were gathered from publicly available sources in the 7 countries, including national standard treatment guidelines, essential medicines lists, drug formularies, national strategies and plans, national road maps, programmatic reports, and intrapartum protocols. If any of these sources were not readily available, we reached out to in-country contacts to obtain them where possible. See Table 1 for examples of select documents reviewed in each country. Secondary data were further supplemented by the 2015 Health Management Information System Maternal and Newborn Health Indicator Survey,12 conducted in 23 of USAID’s priority maternal and child health countries. Demographic data from the Every Preemie—SCALE country profiles for preterm and low birth weight prevention and care,13 published in 2015, were also included as a fourth component. Additional secondary data were obtained from the most recent global Countdown to 2015 reports14,15 and a WHO survey on behalf of the UNCoLSC.16 We summarized the relevant information on the use of ACS in each country and used it to validate information provided by the key informants. Data collection and verification occurred from February to June 2016. Examples of Select Documents Reviewed by Country Abbreviations: ACS, antenatal corticosteroids; DRC, Democratic Republic of the Congo; FMOH, Federal Ministry of Health; MOH, Ministry of Health; RMNCH, reproductive, maternal, newborn, and child health; STG, standard treatment guidelines. Interview questions were based on the 5 WHO conditions for safe ACS use and included whether or not ACS is in use in each country and at what level of care, and the availability of clinical guidelines to determine if a woman is at risk of imminent preterm birth, the presence of maternal infection, gestational age parameters for ACS use, and how to establish accurate measures for gestational age during pregnancy. In the analysis we also looked at the availability of comprehensive emergency obstetric care services and special newborn care services, including the availability of NICUs. The key informant questionnaire focused on national-level ACS policy and implementation and was derived from a framework that laid out the overall objectives of the landscape analysis and key research questions. The framework was shared with members of the ACS Technical Working Group (under the UNCoLSC Newborn Health Technical Reference Team) for their review and input. Key informants were queried on the strengths of implementation as well as existing challenges and barriers. Knowledgeable local and global experts nominated key informants in each of the Pathfinder countries, providing a purposeful sample. At least 1 key informant for every country was a senior-level ministry of health representative. Additional informants, if available, came from organizations working closely with the ministry of health for the respective country. In 7 of the 8 Pathfinder countries, key informants participated in interviews. Despite several attempts to reach suggested key informants in Senegal, efforts were unsuccessful. Senegal was therefore omitted from the study. We interviewed key informants, including at least 1 senior ministry of health official in each country. The study team conducted interviews with 1 to 4 key informants in each of the 7 countries. Representatives from each country had relevant experience and information regarding the use of ACS for women at imminent risk of preterm labor and were able to provide valuable insights. Whenever possible, we conducted key informant interviews by phone or in person during a 4-week period between April 6 and May 6, 2016. We used a structured questionnaire with 29 defined questions for the key informant interviews. The questions promoted discussion and allowed for follow-up and clarification by the interviewer. Each interview took approximately 45 minutes. Three participants received an electronic copy of the written questionnaire to record their written responses due to challenges related to language or telephone connection issues. The questionnaire was also professionally translated into French for key informants from the DRC who preferred to provide written responses in French. See Table 2 for the number of key informants and method of interview by country. Number of Key Informants and Method of Interview by Country Abbreviation: DRC, Democratic Republic of the Congo. In every case possible, we verified the key informant interview data using country-level documents obtained from the desk review. However, verification of key informant data was not possible for reported care practices or the quality of those practices, such as adequate childbirth care and preterm newborn care. The study team made every effort to identify all of the available secondary information for review and analysis in each country. Although it is possible that we missed documents or did not identify a more up-to-date version, our team used multiple sources to identify the most current and relevant materials to mitigate this risk. In the case of inconsistencies between the raw data provided from the Countdown to 2015 reports,14,15 the WHO survey on behalf of the UNCoLSC, and the secondary data obtained through the desk review, the study team attempted to contact the authors of the Countdown to 2015 and WHO reports to obtain more information on the protocols used for their surveys to resolve inconsistencies.
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