Figures & Tables
Tables
Country National Document DRC Maternal, Newborn, and Child Standards of Health User Manual, April 2015
Integrated Maternal, Newborn, and Child Standards for Health, Volume 2: Obstetric Emergency Care, April 2012
Obstetric Care Training and Neonatal Emergency Facilitators Guide, May 2012
Ethiopia FMOH STGs for Primary Hospitals, 2014
FMOH STGs for General Hospitals, 2014
FMOH STGs for Health Centers, 2010
FMOH Management Protocol on Selected Obstetrics Topics for Health Centers, 2014
FMOH Basic Emergency Obstetric and Newborn Care Training Manual, 2013
Malawi Malawi STGs Incorporating Malawi Essential Medicines List, 2015
Malawi National Reproductive Health Service Delivery Guidelines, 2014–2019
Participants Manual in Integrated Maternal and Neonatal Care, 2015
Reproductive Health Unit Obstetric Management Protocols
Nigeria Report of Expert Consensus Panel on the use of ACS, October 2014
MOH National Strategic Health Development Plan 2010–2015
“Saving One Million Lives” Accelerating improvements in Nigeria's Health Outcomes through a new approach to basic services delivery, 2012
Sierra Leone Basic Package of Essential Health Services for Sierra Leone 2015–2020, 2015
Reproductive, Newborn and Child Health Strategy 2011–2015
Maternity Africa: Policies and Guidelines for Intrapartum Postnatal and Neonatal Care
Essential Obstetric and Newborn Care: Practical Guide for Midwives, Doctors With Obstetrics Training and Health Care Personnel Who Deal With Obstetric Emergencies, 2015
Tanzania Administration of Antenatal Corticosteroids in Pre-Term Labour, July 2015, Guidelines
Standard Treatment Guidelines and Essential Medicines List, Fourth Edition, 2013
Health Sector Strategic Plan July 2015–June 2020
Uganda MOH Uganda Guidelines, 2012
MOH Uganda Clinical Guidelines and Essential Medicines and Health Supplies List for Uganda, 2012, Addendum 2: RMNCH Lifesaving Commodities
Essential Medicines and Health Supplies List for Uganda, 2012
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.
Country Number of Key Informants Method of Interview DRC 2 Phone interviews and written questionnaire Ethiopia 1 Phone interview Malawi 2 In-person interviews Nigeria 1 Phone interview Sierra Leone 4 Phone interviews and written questionnaire Tanzania 1 Written questionnaire Uganda 1 In-person interview Abbreviation: DRC, Democratic Republic of the Congo.
- TABLE 3.
ACS Use by Country: Level of Care, Indications for Use, and Pre-Referral Dose Authorization
Country Level of Care Approved for ACS Use Level of Care Where ACS Actually in Use Indications for Use Pre-Referral Dose Allowed DRC Tertiary and maternity hospitals Tertiary and maternity hospital in capital only pPROM, eclampsia, preterm labor No Ethiopia Referral, general, primary hospitals, and health centers Tertiary and secondary hospitals Preterm labor Yes Malawi Central and district hospitals Central and district hospitals Preterm labor No Nigeria Tertiary hospitals Tertiary hospitals Preterm labor No Sierra Leone Tertiary hospitals including district referral hospitals Tertiary and district referral hospitals None No Tanzania Hospitals, health centers Hospitals Preterm labor Yes Uganda Hospitals, health centers IV, III, and II Hospitals, health center IV pPROM and “risk of preterm delivery” Yes Abbreviations: ACS, antenatal corticosteroids; DRC, Democratic Republic of the Congo; pPROM, preterm premature rupture of the membranes.
- TABLE 4.
Inclusion of WHO Care Conditions Required for ACS Use in National Clinical Protocols or Standard Treatment Guidelines, by Countrya
WHO Condition for ACS Therapy Gestational Age Can Be Accurately Undertaken Preterm Birth Is Considered Imminent No Clinical Evidence of Maternal Infection Adequate Childbirth Care Is Available Adequate Preterm Newborn Care Is Available DRC No No Yes Yes Yes Ethiopia No Yes Yes Yes Yes Malawi No No No Yes Yes Nigeria No No No Yes Yes Sierra Leone No info No info No info No info No info Tanzania No No No Yes No Uganda No Yes Yes Yes Yes Abbreviations: ACS, antenatal corticosteroids; DRC, Democratic Republic of the Congo; WHO, World Health Organization.
↵a Yes: WHO condition included in country protocols or guidelines; No: WHO condition not included in country protocols or guidelines.
Country Gestational Age Criteria Source DRC 28–34 weeks National-level document19 Ethiopia 28–34 weeks National-level document20,21 Malawi <34 weeks
28–34 weeks
24–37 weeksNational-level document22,23
(Note: Criteria varied between national documents available for review.)Nigeria 30–34 weeks Key informant, no national-level document Sierra Leone 28–35 weeks Key informant, no national-level document Tanzania 28–34 weeks National-level document24
(Note: ACS could be provided as low as 24 weeks if birth is at a well-equipped facility with a specialist available to manage the premature newborn.)Uganda 32–37 weeks National-level document25 Abbreviations: ACS, antenatal corticosteroids; DRC, Democratic Republic of the Congo.
- TABLE 6.
Preterm Newborn Care Interventions Recommended by WHO for Safe and Effective ACS Use Reported by Key Informants as Being Available at Facilities Providing ACS, by Country
Preterm Newborn Care Interventions Country Resuscitation Thermal Care Infection Prevention and Treatment Feeding Support Safe Oxygen Use DRC Bag and mask
Skin-to-skin contact/KMC
Incubators (not prevalent)
Handwashing
Antibiotics
Separate unit for sick babies
NG tube
Daily weight monitoring
Daily intake monitoring
Oxygen mixer
Oxygen titration
Pulse oximetry
Ethiopia Bag and mask
Drying, cleaning, wrapping
Skin-to-skin contact/KMC
Radiant warmers/incubators
Handwashing
Antibiotics
Sterilization of equipment
Exclusive breastfeeding
Expressed breast milk
NG tube
Daily weight monitoring
Oxygen titration
Oxygen concentrator
Malawi Bag and mask
Skin-to-skin contact
Incubators (some available)
Handwashing
Antibiotics
Separate ward for sick babies
Expressed breast milk
NG tube
Daily weight monitoring
Oxygen mixer
Oxygen titration
Pulse oximetry
Nigeria Bag and mask
KMC
Incubators (at general hospitals)
Antibiotics
Aseptic technique
Separate ward for sick babies
Breastfeeding and all feeding alternatives
NG tube (general and teaching hospitals)
Pulse oximetry
Sierra Leone Bag and mask
Dry, warm, stimulate
KMC
Antibiotics
Expressed breast milk
Formula
NG tube
Daily weight monitoring
Oxygen mixer
Pulse oximetry
Tanzania Bag and mask
Skin-to-skin contact
Incubators
Handwashing
Antibiotics
Separate ward for sick babies
Expressed breast milk
NG tube
Daily weight monitoring
Oxygen mixer
Oxygen titration
Pulse oximetry
Uganda Bag and mask
Skin-to-skin contact
Incubators (limited supply and irregular power supply)
Handwashing
Antibiotics
Separate ward for sick babies
Expressed breast milk
NG tube
Daily weight monitoring
Oxygen mixer/concentrator (limited use due to irregular power supply)
Abbreviations: ACS, antenatal corticosteroids; DRC, Democratic Republic of the Congo; NG, nasogastric; KMC, kangaroo mother care; WHO, World Health Organization.
- TABLE 7.
ACS Implementation Lessons Learned, Strengths, Opportunities, and Challenges Reported by Key Informants
Lessons Learned ACS should be added to the EML for obstetric use
Intervention needs to be cost-effective
Need comprehensive package, not just guidelines
Stakeholders need to be informed of new WHO recommendations
Policies, guidelines, preservice education, in-service education, and regulatory bodies all need alignment
Need increased community awareness of preterm birth
Strengths Ministry of health involvement and ownership
Guidelines and policies exist for most countries
Strong political will and partner support exist for this intervention
Opportunities Expand standards and guidelines to include assessment (i.e., how to determine who should receive ACS)
Need studies of ACS impact at scale
Partner commitment, political will
Strengthen quality of ANC
Increase community awareness to reduce delay in diagnosis
Challenges Inadequate training and capacity building
Inadequate information available to safely scale up the intervention in low-income countries
Delay in diagnosis of preterm labor
ACS not in preservice training
Poor supply chain
Lack of trained health care workers
No specific implementation guidelines for new WHO recommendations
Lack of diagnostics such as ultrasound to determine gestational age
Many deliveries are occurring at lower-level facilities where it is not appropriate to provide ACS
Abbreviations: ACS, antenatal corticosteroids; ANC, antenatal care; EML, essential medicines list; WHO, World Health Organization.