AN EXPLORATION OF OPINION AND PRACTICE PATTERNS AFFECTING LOW USE OF ANTENATAL CORTICOSTEROIDS

One of the major challenges in modern obstetrics is the prevention of preterm birth, especially the birth of a very preterm infant. Preterm birth is associated with most of all neonatal deaths and is a major cause of infant morbidity. To date little evidence exists that obstetric care is effective in reducing the preterm delivery rate.(1) In fact recent data indicate that from 1981 to 1991 a small increase occurred in preterm births, especially among African-American women.(2) Better women. management of preterm labor and delivery and advances in neonatal medicine have contributed to the increased survival of preterm infants. Although most survive, many of these very preterm babies end up with serious long-term complications as a result of prematurity-related conditions such as respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC). Therefore more attention is being given to secondary prevention strategies that may reduce these negative outcomes. One of the few interventions available to obstetricians that has been demonstrated to be effective in reducing the negative sequelae associated with preterm birth is the antenatal administration of corticosteroids. In 1972 Liggins and Howie(3) introduced this therapy as a means of enhancing fetal lung maturity. Since then, numerous clinical trials have demonstrated the benefits of corticosteroid therapy in reducing neonatal morbidity and mortality. In 1990 Crowley et al.,(4) published a metaanalysis of 12 of these clinical trials and found that corticosteroids are effective not only in reducing the occurrence of RDS overall but also in many of the subgroups studied in the trials. They also found that corticosteroid use was associated with a reduction in the incidence of IVH, NEC, and neonatal death. They did not find evidence of any adverse effects of corticosteroids on the mother or the baby. Despite the strength of the evidence regarding the effectiveness of antenatal corticosteroids in reducing the rate and severity of RDS in premature infants, corticosteroids are given to a relatively small number of women who deliver prematurely, Evidence from several sources indicates that only about 20% of mothers who deliver preterm newborns receive corticosteroids.(5) The purpose of this study was to better understand why antenatal corticosteroid therapy is used so rarely. To this end, the investigators sought in-depth information about the variations in obstetrician opinions and practice patterns that might encourage or hinder appropriate corticosteroid use.