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

doi:10.9745/GHSP-D-18-00171

Figures & Tables

Tables

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TABLE 1.

Examples of Select Documents Reviewed by Country

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.

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TABLE 2.

Number of Key Informants and Method of Interview by Country

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.

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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.

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TABLE 4.

Inclusion of WHO Care Conditions Required for ACS Use in National Clinical Protocols or Standard Treatment Guidelines, by Country^a

	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.

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TABLE 5.

Gestational Age Parameters for ACS Use and Source by Country

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 weeks	National-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.

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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
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.

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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