Correspondence

Antenatal there is no evidence of a similar eff ect have a greater eff ect in the absence of corticosteroids to in populations in high-income regions level 2 care, not a lesser eff ect”, but the in the USA or Europe.1,2 evidence to support this statement is reduce preterm deaths Our concern arose because of weak. Any policy to extend antenatal in low-income settings reports implying that antenatal corticosteroid delivery to mothers corticosteroids could be scaled up as through community health-care Authors’ reply a vertical treatment administered to workers in regions where access to We agree with many of the women with signs of preterm labour good-quality specialised care is not correspondents’ points. First, we by community health-care workers, or available (and where the assessment concur that antenatal corticosteroid at outreach clinics without specialised of gestational age and duration treatment can reduce respiratory level-2 health-care facilities. Two of pregnancy is often unreliable) distress in infants born at less than potential risks from this setting could should be on the basis of randomised 34 weeks’ gestation. Second, we outweigh the benefi ts: the possibility community effectiveness trials. welcome the rapid scale-up of its use that the number needed to treat, to The risks and benefits can then be in hospitals in Malawi, as described save the life of a preterm infant, could measured in the same way that those by Stephen Kaliti, and look forward increase the incidence of serious of dietary vitamin A, chlorhexidine, to the published assessment of sepsis in mothers, and second, death and zinc supplementation have been its effect on mortality in preterm or disability might occur later as a assessed in populations in low-income infants. Third, we agree that more result of suboptimal preterm care. regions.5,6 We urge funders to support research is needed to explore the best Globally, 40 million women deliver these studies. methods for scale-up in hospitals and their babies at home every year and We declare that we have no competing interests. to assess the risks and benefits to many more face formidable economic, Copyright © Azad et al. Open Access article patients through community studies cultural, and geographical barriers distributed under the terms of CC BY. in low-income regions. Particularly, to accessing good-quality maternity Kishwar Azad, * we anticipate findings of a trial of health care. Many of these women [email protected] antenatal corticosteroid treatment live in low-income regions and rural Perinatal Care Project, Diabetic Association of that is underway in several countries populations in Africa and south Asia Bangladesh, Dhaka, Bangladesh (KA); Institute for and in which 90 000 infants have and endure high levels of malnutrition, Global Health, University College London, been enrolled. especially a lack of micronutrients 30 Guilford Street, London WC1N 1EH, UK (AC) Conversely, we are not in agree- and protein, malaria, anaemia, and 1 WHO Guidelines Approved by the Guidelines Review Committee. Guideline: vitamin A ment with Joy Lawn and colleagues worm infestations that combined supplementation in infants 1–5 months of who suggest that it is, “extremely with the immunosuppressive effect age. Geneva: World Health Organization, 2011. unlikely, statistically, that antenatal of pregnancy or HIV infection might 2 Prost A, Colbourn T, Seward N, et al. Women’s groups practising participatory learning and corticosteroids would be shown not increase their vulnerability to sepsis. action to improve maternal and newborn to work in African or Asian babies”. In the USA, chorioamnionitis aff ects health in resource-limited settings: systematic review and meta-analysis. Lancet 2013; Our point about the potential 9% of pregnancies, but the burden 381: 1736–46. risks associated with antenatal of placental infection is much higher 3 Malloy MH. Chorioamnionitis: corticosteroid scale-up was not a in Africa and Asia.3,4 We agree with of newborn management and outcome United States 2008. J Perinatol 2014; published question of efficacy, or ethnicity, Caroline Crowther and Julie Brown online May 1. DOI:10.1038/jp.2014.81. but instead the underlying risks and that a paucity of evidence exists for 4 Chico RM, Mayaud P, Ariti C, Mabey D, benefi ts of antenatal corticosteroids the effect of dexamethasone on Ronsmans C, Chandramohan D. Prevalence of malaria and sexually transmitted and to populations in low-income maternal infection, anywhere, and a reproductive tract infections in pregnancy in regions and diff erent levels of access complete absence of evidence exists sub-Saharan Africa: a systematic review. JAMA 2012 6; 307: 2079–86. to health care. These factors can in low-income settings. Health-care 5 El Arifeen S, Mullany LC, Shah R, et al. strikingly change the benefi t-to-risk workers need to be sure, however, The eff ect of cord cleansing with chlorhexidine ratio of interventions. For example, that antenatal corticosteroids do on neonatal mortality in rural Bangladesh: a community-based, cluster-randomised trial. in low-income regions in south not exacerbate the severity, or 2012; 379: 1022–28. Asia and Africa, dietary vitamin A dissemination, of maternal infections 6 Mori R, Ota E, Middleton P, Tobe-Gai R, Mahomed K, Bhutta ZA. Zinc supplementation supplementation in rural populations in these communities. for improving pregnancy and infant outcome. and participatory women’s groups Stephen Kaliti suggests that, Cochrane Database Syst Rev 2012; 7: CD000230. had a large eff ect on child survival, but “antenatal corticosteroids are likely to

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