Dr. Ina Castro describes the typical scenario women with complications from pre-term labor experience when arriving at government hospitals in the Philippines: “The women coming from the rural health facilities in island municipalities have to travel two to four hours by boat. By the time they get to the referral hospital for treatment, it has been too long. And when they finally do manage to arrive, there may be no doctor available in the emergency room, so the patient is not assessed right away.”
The danger for these women’s babies can be great. If born before 37 weeks gestation, they are at risk for various complications, including immature lungs, severe disability, or even death. In fact, death from complications of pre-term birth is the leading cause of newborn mortality in the Philippines and worldwide, resulting in more than one million deaths per year.
However, many of these deaths can be prevented with an inexpensive medication called dexamethasone—a common antenatal corticosteroids (ACS). When given correctly to women who have a complication that can lead to early delivery, dexamethasone acts on fetal lungs, brain and other organs to briefly speed up development. And although the administration of ACS before birth is one of the most beneficial interventions for improving newborn outcomes among women who give birth prematurely, it has been underutilized in most low- and middle-income countries. In fact, death from complications of pre-term birth is the leading cause of newborn mortality in the Philippines and worldwide, resulting in more than one million deaths per year.
With one of the highest pre-term birth rates in the world (at 14.9% in 2010), the Philippines is no different. With this in mind, USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) partnered with the country’s Ministry of Health—in addition to those in Cambodia and Indonesia—for an innovative pilot study to learn how to increase the number of women who receive this lifesaving medicine.
Dr. Castro, the study coordinator for the Philippines sites, is encouraged by the early results from the study. This is particularly true of one of the six pilot hospitals—Dr. Paulino J. Garcia Memorial Research and Medical Center—where almost all women at risk of pre-term birth are now receiving dexamethasone. Moreover, the Philippine Ministry of Health has expressed interest in scaling up this important intervention to other hospitals around the country.
According to Dr. Castro, success increasing the use of dexamethasone at this hospital can be traced in part to a policy initiated by the obstetrics department during the study to allow nurses to administer the medicine to women when they arrive at the hospital’s emergency room. Due to the heavy workload in this busy hospital, the doctor on duty may not be immediately available to evaluate the woman and initiate the treatment, causing an unnecessary delay in care. “So allowing nurses to assess women and initiate care based on standard protocols and doctors’ verbal order will help a lot,” Dr. Castro says.
“What we learn from these studies will have substantial implications for reducing newborn mortality in many of the countries where we work,” says Dr. Jeffrey Smith, Maternal Health Team Leader for MCHIP, and the lead for the study. Dr. Smith will share the results and engage partners in a discussion of next steps at an August 4-5 ACS Working Meeting convened by UN Commission on Lifesaving Commodities (UNCoLSC) with support and participation of the Bill & Melinda Gates Foundation (BMGF), MCHIP and key partners (such as Survive & Thrive and Born Too Soon). The objective of the meeting is to advance an implementation package for even broader scale up of ACS, and represents a culmination of partners’ collaborative and multi-faceted efforts in the areas of advocacy, operations research, and resource development to successfully expand the use of ACS.
At this meeting, MCHIP and the Survive & Thrive Global Development Alliance will present a new, simple training module on the use of ACS developed under the Helping Babies Survive and Helping Mothers Survive series. The training materials will use the same approach as Helping Babies Breathe to improve the capacity of providers and advocate for the management of pre-term births using a perinatal team approach—an approach characterized by communication and collaboration in care decisions among newborn and maternal health providers.
While these training materials will go a long way to promoting greater coverage of ACS, challenges remain and more evidence to guide expansion is needed. Recently, in a commentary published in the The Lancet, advocates raised concerns about the efficacy, safety and appropriate gestational age at which to give ACS to patients in low-income countries. MCHIP joined other public health experts—led by Joy E. Lawn of the London School of Hygiene and Tropical Medicine—to address these concerns and call for continued implementation in a response letter published in The Lancet Global Health. Current evidence shows that a single course of ACS can reduce mortality among babies born prematurely by more than 30%, with a very low risk of adverse effects.
The authors of the letter argued that there is strong evidence about the benefits of ACS and the limited potential harms. Current evidence shows that a single course of ACS can reduce mortality among babies born prematurely by more than 30%, with a very low risk of adverse effects. The letter also addressed the challenge of gestational age assessment, and suggested that when gestational age of an infant is unknown or unclear, the benefits of treatment likely outweigh the risks in high mortality settings.
Through this and other initiatives under way, MCHIP is working in partnership with the BMGF, Survive & Thrive, UNCoLSC and others to advance the use of ACS as an important clinical and public health intervention to reduce newborn mortality. The hope is that these combined efforts—with their focus on collaborative perinatal approaches to care—will allow for the expanded use of this simple intervention by more providers working in hospitals that care for mothers and newborns, thus increasing access to this lifesaving practice.
Dr. Castro summed it up nicely, “Dexamethasone is very inexpensive and the benefits are substantial, so we need to increase its appropriate use.”
 Other components of this perinatal team approach include: standard treatment protocols that are understood, agreed upon, and followed; a perinatal audit system; and regular meetings of the perinatal team to review progress and share individual patient outcomes.