Format

Send to

Choose Destination
Reprod Health. 2016 May 24;13(1):64. doi: 10.1186/s12978-016-0179-z.

The Antenatal Corticosteroids Trial (ACT): a secondary analysis to explore site differences in a multi-country trial.

Author information

1
Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina. kklein@iecs.org.ar.
2
RTI International, Durham, NC, USA.
3
Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.
4
Massachusetts General Hospital, Boston, MA, USA.
5
Moi University School of Medicine, Eldoret, Kenya.
6
Fundación para la Alimentación y Nutrición de Centro América y Panamá, Guatemala City, Guatemala.
7
Lata Medical Research Foundation, Indira Gandhi Government Medical College, Nagpur, India.
8
Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
9
University Teaching Hospital, Lusaka, Zambia.
10
University of Alabama at Birmingham, Birmingham, AL, USA.
11
University of Colorado School of Medicine, Denver, Colorado, USA.
12
KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India.
13
Christiana Health Care, Newark, DE, USA.
14
School of Medicine, Indiana University, Indianapolis, IN, USA.
15
Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
16
Tulane School of Public Health & Tropical Medicine, New Orleans, Louisiana, USA.
17
Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA.

Abstract

BACKGROUND:

The Antenatal Corticosteroid Trial (ACT) assessed the feasibility, effectiveness, and safety of a multifaceted intervention to increase the use of antenatal corticosteroids (ACS) in mothers at risk of preterm birth at all levels of care in low and middle-income countries. The intervention effectively increased the use of ACS but had no overall impact on neonatal mortality in the targeted <5(th) percentile birth weight infants. Being in the intervention clusters was also associated with an overall increase in neonatal deaths. We sought to explore plausible pathways through which this intervention increased neonatal mortality.

METHODS:

We conducted secondary analyses to assess site differences in outcome and potential explanations for the differences in outcomes if found. By site, and in the intervention and control clusters, we evaluated characteristics of the mothers and care systems, the proportion of the <5(th) percentile infants and the overall population that received ACS, the rates of possible severe bacterial infection (pSBI), determined from clinical signs, and neonatal mortality rates.

RESULTS:

There were substantial differences between the sites in both participant and health system characteristics, with Guatemala and Argentina generally having the highest levels of care. In some sites there were substantial differences in the health system characteristics between the intervention and control clusters. The increase in ACS in the intervention clusters was similar among the sites. While overall, there was no difference in neonatal mortality among <5(th) percentile births between the intervention and control clusters, Guatemala and Pakistan both had significant reductions in neonatal mortality in the <5(th) percentile infants in the intervention clusters. The improvement in neonatal mortality in the Guatemalan site in the <5(th) percentile infants was associated with a higher level of care at the site and an improvement in care in the intervention clusters. There was a significant increase overall in neonatal mortality in the intervention clusters compared to the control. Across sites, this increase in neonatal mortality was statistically significant and most apparent in the African sites. This increase in neonatal mortality was accompanied by a significant increase in pSBI in the African sites.

CONCLUSIONS:

The improvement in neonatal mortality in the Guatemalan site in the <5(th) percentile infants was associated with a higher level of care and an improvement in care in the intervention clusters. The increase in neonatal mortality in the intervention clusters across all sites was largely driven by the poorer outcomes in the African sites, which also had an increase in pSBI in the intervention clusters. We emphasize that these results come from secondary analyses. Additional prospective studies are needed to assess the effectiveness and safety of ACS on neonatal health in low resource settings.

TRIAL REGISTRATION:

TRIAL REGISTRATION:

clinicaltrials.gov (NCT01084096).

PMID:
27221319
PMCID:
PMC4878061
DOI:
10.1186/s12978-016-0179-z
[Indexed for MEDLINE]
Free PMC Article

Supplemental Content

Full text links

Icon for BioMed Central Icon for PubMed Central
Loading ...
Support Center