The triplets born in a hospital in Kabul, Afghanistan, weighed less than four pounds each. As is common with multiples, they were born too early, which should have been a red flag to the midwives that these babies would need to be closely observed for potential complications. Visiting midwife trainer Sheena Currie—now an MCHIP advisor—briefly saw the mother and her babies after the birth. But when she returned hours later to check on them, she was horrified to learn they had already gone home. When Ms. Currie questioned hospital staff about the early discharge, she was told “the babies were fine.”
However, the lungs of preterm babies—those born before 37 weeks gestation—are at risk for various complications, including immature lungs. As a result, the babies had an increased risk of developing respiratory distress syndrome (RDS), a condition marked by difficulty breathing. With RDS, newborns can appear fine immediately after delivery, but four to six hours later, breathing difficulties can develop. Without immediate medical attention, most babies with RDS will not survive, or will develop severe disabilities. RDS is an important cause of newborn death and disability for babies born prematurely. In fact, complications of prematurity is now the number one cause of newborn death globally, resulting in more than 1 million deaths per year, and also the second cause of mortality in children under 5 years of age.
Mother and newborn in Afghanistan. (Photo courtesy of Jhpiego.)
Fortunately, giving women Antenatal Corticosteroids (ACS) has been identified as a highly effective intervention to improve newborn outcomes. Therefore, USAID’s Flagship Maternal and Child Health Integrated Program (MCHIP) is spearheading the production and dissemination of ACS related job aids and briefers. The ACS advocacy briefer—developed in collaboration with the World Health Organization (WHO), the Bill & Melinda Gates Foundation, Survive & Thrive, and “Born too Soon”— addresses how and why ACS administration should be scaled up in developing countries, and highlights its value as an effective intervention to save newborn lives. A complementary technical briefer describes the proper clinical use of ACS to improve outcomes for preterm newborns.
While the administration of ACS before birth is the single most beneficial intervention for improving newborn outcomes among women who give birth prematurely, it has been underutilized in most low- and middle-income countries.
“Malaria is one of the leading causes of prematurity in Africa,” said Dr. Blami Dao, Jhpiego’s Maternal and Newborn Health Technical Director.
He explained that “while tocolytic agents (medicines to stop uterine contractions) are widely used in preterm labor, ACS is often forgotten.” Importantly, tocolytic agents may prolong pregnancy for a short time (up to 48 hours), to allow for the administration of ACS to speed up fetal lung development. Blami attributes the low usage rates of ACS to supply issues, and to a failure to update clinical guidelines and protocols promoting their use.
In contrast, guidelines on the use of ACS are generally available in many Latin American countries, according to Dr. Vicente Bataglia, MCHIP Chief of Party in Paraguay. However, even when providers know that ACS are useful in threatened preterm birth, there is no standardization or uniformity in how they are used.
“In practice, providers may not be clear about the correct gestational age (number of weeks pregnant), and they don’t always use the preferred medicine or the right dose at the right time,” Dr. Bataglia said. “There is a critical window of time when ACS should be used. Providers sometimes try to give it after 34 weeks, when it won’t have much of an effect, or they fail to use it when it would have a hugely beneficial effect.”
He found the innovative new job aid on threatened preterm birth, developed by MCHIP and the Bill & Melinda Gates Foundation, particularly useful. Aimed a clinicians, implementers and trainers, this tool gives explicit guidance about when to give ACS, and clearly states the correct drugs, dosage, and timing to administer.
Because MCHIP works in more than 50 countries, the impact of this well-coordinated drive to promote ACS—with key collaborating partners—has the potential to be far-reaching. Through MCHIP’s integrated approach, targeted efforts to promote the availability and the appropriate use of ACS will help improve the health of countless newborns.