Medications for premature deliveries underutilized in developing world

1. In women who delivered prematurely after 22 weeks’ gestation and were eligible for tocolytic drugs, only 18% received both tocolytic drugs and antenatal corticosteroids.  21% received tocolytic drugs alone, 27% were treated with bed rest and hydration, and 48% received no treatment. 

2. Use of tocolytic drugs and antenatal corticosteroids was highly variable in the countries studied, as antenatal corticosteroid use averaged 54%,while tocolytic drug use averaged 19%. 

Evidence Rating Level: 2 (Good) 

Study Rundown: Morbidity and mortality from spontaneous preterm labor can be reduced by using tocolytic drugs that temporarily suppress contractions and delay delivery along with injections of corticosteroids before delivery that induce fetal lung maturation. This study utilized data from the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS) to assess the use of tocolytic drugs in spontaneous preterm deliveries and describe patterns of use of antenatal corticosteroids in preterm deliveries in low and middle-income countries.

The results showed that tocolytic drugs and antenatal corticosteroids were extensively underutilized in patients in whom they could have been beneficial. Nearly half of eligible women who delivered preterm did not receive antenatal corticosteroids, and among women eligible for tocolytic treatment, almost half received no treatment and a quarter received non-drug treatments. The use of tocolytic drugs and antenatal corticosteroids was also highly variable in the countries studied. Although this study was the first comparison of tocolytic drug use and antenatal corticosteroids in preterm birth across low-and middle-income countries, this analysis may be limited by poor estimations of gestational age. The recorded preterm birth rate was lower than expected according to recent estimates, and could have been the basis of potential overestimates. The authors stated that despite evidence showing the effectiveness of tocolytic drugs and antenatal corticosteroids, use was poor and highly variable in this study, suggesting that improved drug availability and health policy is needed.

This study was funded by 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, and Gynuity Health Projects

Click to read the study, published today in The Lancet

Relevant Reading: Antenatal steroids in preterm labour for the prevention of neonatal deaths due to complications of preterm birth

In-Depth [retrospective cohort]: This study analyzed previous data collected from May 1, 2010 to Dec. 31 2011 from WHOMCS, a cross-sectional survey database of birth outcomes in 359 facilities in 29 countries in Africa, Asia, Latin America, and the Middle East. Preterm deliveries at and after 22 weeks’ gestation were categorized into three groups: 22-25 weeks, 26-34 weeks, and 35-36 weeks of gestation. Tocolytic drugs were grouped into 5 classes: β-agonists, NSAIDs and COX-inhibitors, calcium-channel blockers, oxytocin antagonists, and magnesium sulfate. Antenatal corticosteroid use was assessed in all groups, while tocolytic drug use with and without antenatal corticosteroids was assessed in women with spontaneous preterm labor at 26-34 weeks’ gestation.

303,842 deliveries were recorded after 22 weeks’ gestation, with 17,705 (6%) classified as preterm. 4,677 women were potentially eligible to receive tocolytic drugs, in which 970 (21%) received tocolytic drugs, 2,248 (48%) received no treatment, 1,276 (27%) were treated with bed rest or hydration, and 848 (18%) received both a tocolytic drug and antenatal corticosteroids. The most common tocolytic drugs administered were β-agonists, which are associated with higher rates of maternal adverse effects. Antenatal corticosteroids were given to 94 of 497 (19%) women who gave birth at 22-25 weeks, 3,900 of 7,547 (52%) women at 26-34 weeks, and 2,276 of 9,661 (24%) women at 35-36 weeks. Antenatal corticosteroid use averaged 54% in the countries studied (range 16-91%, Interquartile Range 30-68%), while tocolytic drugs averaged 19% (range 0-100). Although this study was unable to specifically identify barriers for the use of tocolytic drugs and antenatal corticosteroids, women with little education as well as younger women were less likely to receive corticosteroids, suggesting social inequality as a basis to this disparity.

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