The scientific basis for antenatal corticosteroids (ACS) for women at risk of preterm birth has rapidly changed in recent years. Two landmark trials—the Antenatal Corticosteroid Trial and the Antenatal Late Preterm Steroids Trial—have challenged the long-held assumptions on the comparative health benefits and harms regarding the use of ACS for preterm birth across all levels of care and contexts, including resource-limited settings. Researchers, clinicians, programme managers, policymakers and donors working in low-income and middle-income countries now face challenging questions of whether, where and how ACS can be used to optimise outcomes for both women and preterm newborns.
In this article, we briefly present an appraisal of the current evidence around ACS, how these findings informed WHO’s current recommendations on ACS use, and the knowledge gaps that have emerged in the light of new trial evidence. Critical considerations in the generalisability of the available evidence demonstrate that a true state of clinical equipoise exists for this treatment option in low-resource settings. An expert group convened by WHO concluded that there is a clear need for more efficacy trials of ACS in these settings to inform clinical practice.
- preterm birth
- antenatal corticosteroids
- neonatal mortality
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Handling editor Seye Abimbola
Contributors The named authors were participants in the WHO technical consultation on a multicountry randomised trial of antenatal corticosteroids for women in at risk of imminent preterm birth to improve newborn outcomes, held in Geneva, Switzerland on 12–13 November 2015. The outline and contents of this article were discussed at the consultation. The article was initially drafted by JPV, OTO, CPC, AMG and RB. All named authors provided comments and agreed on the final version of this article. This article represents the views of the named authors only, and does not represent the views of their organisations.
Funding The consultation and the WHO ACTION Trials are supported by a grant from the Bill and Melinda Gates Foundation (grant number OPP1136821). JP is an employee of the Foundation, and provided technical input into the manuscript, which was reviewed by all named authors. The funders had no role in decision to publish. JPV, OTO, CPC, AC, RB and AMG are currently employees of the WHO. At the time of the consultation, MT was an employee of WHO; however, she is currently employed by the Aga Khan Development Network.
Competing interests CC is currently chief investigator on a randomised controlled trial to evaluate the role of maternal intramuscular dexamethasone versus betamethasone prior to preterm birth (A*STEROID Trial). AHJ has consulted for possible therapies for respiratory distress syndrome and bronchopulmonary dysplasia with Chiesi; has received respiratory supplies from Fisher & Paykel and surfactant from Chiesi for animal model research; and has received grant support from the National Institute of Child Health and Development, the National Heart, Lung and Blood Institute, Burroughs Welcome, Glaxo Smith Kline and the Bill and Melinda Gates Foundation for studies with premature animal models. FA is a recipient of a research grant from the Bill and Melinda Gates Foundation. The authors otherwise report they have no competing interests to declare.
Ethics approval WHO Ethics Review Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The data quoted in this paper are already available in the public domain.
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