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ORIGINAL ARTICLE
Open Access

Antenatal Corticosteroids for Women at Risk of Imminent Preterm Birth in 7 sub-Saharan African Countries: A Policy and Implementation Landscape Analysis

Dawn Greensides, Judith Robb-McCord, Angeline Noriega and James A. Litch
Global Health: Science and Practice December 2018, 6(4):644-656; https://doi.org/10.9745/GHSP-D-18-00171
Dawn Greensides
aIndependent consultant, Johannesburg, South Africa.
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  • For correspondence: dawngreensides@gmail.com
Judith Robb-McCord
bEvery Preemie—SCALE/Project Concern International, Washington, DC, USA.
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Angeline Noriega
cIndependent consultant, Portland, OR, USA.
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James A. Litch
dEvery Preemie—SCALE/Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), Seattle, WA, USA.
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Figures & Tables

Tables

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    TABLE 1.

    Examples of Select Documents Reviewed by Country

    CountryNational 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.

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    TABLE 2.

    Number of Key Informants and Method of Interview by Country

    CountryNumber of Key InformantsMethod of Interview
    DRC2Phone interviews and written questionnaire
    Ethiopia1Phone interview
    Malawi2In-person interviews
    Nigeria1Phone interview
    Sierra Leone4Phone interviews and written questionnaire
    Tanzania1Written questionnaire
    Uganda1In-person interview
    • Abbreviation: DRC, Democratic Republic of the Congo.

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    TABLE 3.

    ACS Use by Country: Level of Care, Indications for Use, and Pre-Referral Dose Authorization

    CountryLevel of Care Approved for ACS UseLevel of Care Where ACS Actually in UseIndications for UsePre-Referral Dose Allowed
    DRCTertiary and maternity hospitalsTertiary and maternity hospital in capital onlypPROM, eclampsia, preterm laborNo
    EthiopiaReferral, general, primary hospitals, and health centersTertiary and secondary hospitalsPreterm laborYes
    MalawiCentral and district hospitalsCentral and district hospitalsPreterm laborNo
    NigeriaTertiary hospitalsTertiary hospitalsPreterm laborNo
    Sierra LeoneTertiary hospitals including district referral hospitalsTertiary and district referral hospitalsNoneNo
    TanzaniaHospitals, health centersHospitalsPreterm laborYes
    UgandaHospitals, health centers IV, III, and IIHospitals, health center IVpPROM and “risk of preterm delivery”Yes
    • Abbreviations: ACS, antenatal corticosteroids; DRC, Democratic Republic of the Congo; pPROM, preterm premature rupture of the membranes.

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    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 UndertakenPreterm Birth Is Considered ImminentNo Clinical Evidence of Maternal InfectionAdequate Childbirth Care Is AvailableAdequate Preterm Newborn Care Is Available
    DRCNoNoYesYesYes
    EthiopiaNoYesYesYesYes
    MalawiNoNoNoYesYes
    NigeriaNoNoNoYesYes
    Sierra LeoneNo infoNo infoNo infoNo infoNo info
    TanzaniaNoNoNoYesNo
    UgandaNoYesYesYesYes
    • 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.

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    TABLE 5.

    Gestational Age Parameters for ACS Use and Source by Country

    CountryGestational Age CriteriaSource
    DRC28–34 weeksNational-level document19
    Ethiopia28–34 weeksNational-level document20,21
    Malawi<34 weeks
    28–34 weeks
    24–37 weeks
    National-level document22,23
    (Note: Criteria varied between national documents available for review.)
    Nigeria30–34 weeksKey informant, no national-level document
    Sierra Leone28–35 weeksKey informant, no national-level document
    Tanzania28–34 weeksNational-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.)
    Uganda32–37 weeksNational-level document25
    • Abbreviations: ACS, antenatal corticosteroids; DRC, Democratic Republic of the Congo.

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    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
    CountryResuscitationThermal CareInfection Prevention and TreatmentFeeding SupportSafe 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.

    • View popup
    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.

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Global Health: Science and Practice: 6 (4)
Global Health: Science and Practice
Vol. 6, No. 4
December 27, 2018
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Antenatal Corticosteroids for Women at Risk of Imminent Preterm Birth in 7 sub-Saharan African Countries: A Policy and Implementation Landscape Analysis
Dawn Greensides, Judith Robb-McCord, Angeline Noriega, James A. Litch
Global Health: Science and Practice Dec 2018, 6 (4) 644-656; DOI: 10.9745/GHSP-D-18-00171

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Antenatal Corticosteroids for Women at Risk of Imminent Preterm Birth in 7 sub-Saharan African Countries: A Policy and Implementation Landscape Analysis
Dawn Greensides, Judith Robb-McCord, Angeline Noriega, James A. Litch
Global Health: Science and Practice Dec 2018, 6 (4) 644-656; DOI: 10.9745/GHSP-D-18-00171
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