One-fifth of mothers do not receive recommended antenatal corticosteroids before delivery of premature infants
Strong evidence demonstrates that antenatal corticosteroids during preterm labor reduce the incidence of respiratory distress syndrome and other secondary complications associated with prematurity. Yet, 20 percent of eligible mothers failed to receive indicated antenatal corticosteroid therapy, according to a study at three New York City hospitals. Of these women, 43 percent delivered more than 2 hours after admission and 33 percent delivered more than 4 hours after admission, indicating sufficient time to have treated them.
The failure to administer recommended steroids was related strongly to how long after admission the delivery took place. Seventy-nine women delivered within 2 hours of admission and 73 percent of them did not receive the therapy. By contrast, only 8 percent of those who delivered between six and eight hours after admission did not receive recommended corticosteroids. This may be because the National Institutes of Health (NIH) Consensus Statement (1994) supporting the use of antenatal corticosteroids excludes from its recommendation women for whom immediate delivery was anticipated. Many of the women who delivered within 2 hours of admission were probably expected to deliver immediately, note the researchers.
In this study, women whose cervixes were at a more advanced stage were also less likely to receive steroids, suggesting that physicians chose to withhold steroids from women for whom they anticipated immediate delivery. They were generally correct (if imprecise), but wrong one-third of the time, note the researchers. They state that incorporating a physician's capacity to predict the immediate future regarding the time of delivery may have inadvertently subverted the capacity of the NIH guideline to guide practice. They recommend that the NIH guideline may have been more effectively implemented had the statement suggested that steroids should be provided to all eligible women who do not deliver within a specific time period, such as 1 hour after admission. The other factors associated with failure to receive recommended therapy were lack of prenatal care, longer gestation, advanced cervical exam, and intact membranes at admission.
The study included 515 women eligible for antenatal corticosteroids, of whom 70 percent were black or Hispanic. Most were insured through Medicaid or a Medicaid HMO. This study was supported, in part, by the Agency for Healthcare Research and Quality (HS10859).
See "Approaching NIH guideline recommended care for maternal-infant health: Clinical failures to use recommended antenatal corticosteroids" by Elizabeth A. Howell, M.D., Joanne Stone, M.D., Lawrence C. Kleinman, M.D., and others in the 2010 Maternal and Child Health Journal 14, pp. 430-436.
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