School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Crawley, WA, Australia; UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland.
UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland; Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
Lancet. 2014 Nov 22;384(9957):1869-1877. doi: 10.1016/S0140-6736(14)60580-8. Epub 2014 Aug 12.
Despite the global burden of morbidity and mortality associated with preterm birth, little evidence is available for use of antenatal corticosteroids and tocolytic drugs in preterm births in low-income and middle-income countries. We analysed data from the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS) to assess coverage for these interventions in preterm deliveries.
WHOMCS is a facility-based, cross-sectional survey database of birth outcomes in 359 facilities in 29 countries, with data collected prospectively from May 1, 2010, to Dec 31, 2011. For this analysis, we included deliveries after 22 weeks' gestation and we excluded births that occurred outside a facility or quicker than 3 h after arrival. We calculated use of antenatal corticosteroids in women who gave birth between 26 and 34 weeks' gestation, when antenatal corticosteroids are known to be most beneficial. We also calculated use in women at 22-25 weeks' and 34-36 weeks' gestation. We assessed tocolytic drug use, with and without antenatal corticosteroids, in spontaneous, uncomplicated preterm deliveries at 26-34 weeks' gestation.
Of 303,842 recorded deliveries after 22 weeks' gestation, 17,705 (6%) were preterm. 3900 (52%) of 7547 women who gave birth at 26-34 weeks' gestation, 94 (19%) of 497 women who gave birth at 22-25 weeks' gestation, and 2276 (24%) of 9661 women who gave birth at 35-36 weeks' gestation received antenatal corticosteroids. Rates of antenatal corticosteroid use varied between countries (median 54%, range 16-91%; IQR 30-68%). Of 4677 women who were potentially eligible for tocolysis drugs, 1276 (27%) were treated with bed rest or hydration and 2248 (48%) received no treatment. β-agonists alone (n=346, 7%) were the most frequently used tocolytic drug. Only 848 (18%) of potentially eligible women received both a tocolytic drug and antenatal corticosteroids.
Use of interventions was generally poor, despite evidence for their benefit for newborn babies. A substantial proportion of antenatal corticosteroid use occurred at gestational ages at which benefit is controversial, and use of less effective or potentially harmful tocolytic drugs was common. Implementation research and contextualised health policies are needed to improve drug availability and increase compliance with best obstetric practice.
UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.
尽管早产与全球发病率和死亡率有关，但在中低收入国家，关于产前皮质激素和保胎药物在早产中的应用，几乎没有证据。我们分析了世界卫生组织（WHO）多国家母婴健康调查（WHOMCS）的数据，以评估这些干预措施在早产分娩中的应用情况。
WHOMCS 是一个基于设施的、前瞻性的、横断性的母婴健康调查数据库，包含 29 个国家的 359 个设施的分娩结果，数据于 2010 年 5 月 1 日至 2011 年 12 月 31 日期间收集。本分析中，我们纳入了妊娠 22 周后分娩的病例，并排除了在设施外或分娩后 3 小时内分娩的病例。我们计算了妊娠 26-34 周时使用产前皮质激素的情况，因为此时使用产前皮质激素最有益。我们还计算了妊娠 22-25 周和 34-36 周时使用产前皮质激素的情况。我们评估了妊娠 26-34 周时自发性、无并发症早产时使用和不使用产前皮质激素的保胎药物的情况。
在记录的妊娠 22 周后的 303842 次分娩中，有 17705 次（6%）为早产。在妊娠 26-34 周分娩的 7547 名妇女中，有 3900 名（52%），妊娠 22-25 周分娩的 497 名妇女中，有 94 名（19%），妊娠 35-36 周分娩的 9661 名妇女中，有 2276 名（24%）接受了产前皮质激素治疗。产前皮质激素使用率在各国之间存在差异（中位数 54%，范围 16-91%；IQR 30-68%）。在 4677 名可能有保胎药物使用适应证的妇女中，有 1276 名（27%）接受了卧床休息或补液治疗，2248 名（48%）未接受治疗。β-激动剂（n=346，7%）是最常使用的保胎药物。仅有 848 名（18%）可能有适应证的妇女同时接受了保胎药物和产前皮质激素治疗。
尽管有证据表明这些干预措施对新生儿有益，但它们的应用总体上仍然很差。尽管对产前皮质激素在妊娠 26 周前使用的益处存在争议，但仍有相当一部分妇女在这一时期使用了这种药物，而且使用效果较差或可能对产妇有害的保胎药物也很常见。需要开展实施研究和制定有针对性的卫生政策，以提高药物的可及性并提高最佳产科实践的依从性。
联合国开发计划署/联合国人口基金/联合国儿童基金会/世界卫生组织/世界银行人类生殖研究、发展和研究培训特别方案（HRP）；世界卫生组织；美国国际开发署；日本厚生劳动省；Gynuity 健康项目。
