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Summary Background 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. Methods 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. Findings 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. Interpretation 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. Funding 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.

Women who have a retained placenta are at high risk of postpartum hemorrhage without prompt treatment. The facilities and skilled personnel needed to perform manual removal of the placenta, the current treatment, are often unavailable to women in rural resource-poor settings, and the case fatality rate is nearly 10% in such settings. Some investigators have suggested that administration of oxytocin via the umbilical vein and placenta is a low-cost low technology method that could increase placental expulsion. A number of small studies reported that umbilical injection of oxytocin was an effective intervention, while a meta-analysis (Cochrane review) suggested that this intervention was effective but the results were of borderline significance Two large, high quality studies found no reduction in the rates of retained placenta compared with expectant management. This double-blind, placebo-controlled multicenter trial investigated the effectiveness of treatment with high-dose umbilical vein oxytocin in women with retained placenta. The study was conducted at teaching hospitals in the United Kingdom, Uganda, and Pakistan between 2004 and 2008. The participants were hemodynamically stable women who had a retained placenta for more than 30 minutes. A total of 577 women were randomly assigned to receive 30 ml saline containing either 50 IU oxytocin (n = 292) or 5 mL water (n = 285) via injection into the placenta through an umbilical vein catheter. The need for manual removal of the placenta was the primary outcome measure. No difference between the groups was found in the need for manual placental removal (oxytocin: 61.3% 179/292 vs. placebo: 62.1% 177/285; Relative Risk = 0.98, 95% confidence interval: 0.87-1.12; P = 0.84). There was a difference between the countries in the need for manual removal; the need was higher in the United Kingdom (69% 250/361) than in Uganda (47% 90/190); or Pakistan (62% 16/26). There was no difference in adverse events between the oxytocin and placebo groups. These findings are consistent with the results of other studies showing that umbilical injection of oxytocin has no clinically significant effect on the need for manual removal of the placenta in women with retained placenta, and suggest that other treatment approaches are necessary.

Summary Background Latin America has a high rate of caesarean sections. We tested the hypothesis that a hospital policy of mandatory second opinion, based on the best existing scientific evidence, reduces the hospital caesarean section rate by 25%, without increasing maternal and perinatal morbidity and mortality. Methods 36 hospitals in Argentina (18), Brazil (eight), Cuba (four), Guatemala (two), and Mexico (four), were randomly assigned to intervention or control in a matched pair design. All physicians in the intervention hospitals deciding a non-emergency caesarean section had to follow a policy of mandatory second opinion. The primary outcome was the overall caesarean section rate in the hospitals after a 6-month implementation period. We also assessed women's satisfaction with labour and delivery care and physicians' acceptance of the second opinion policy. Findings A total of 34 hospitals attending 149 276 deliveries were randomised and completed the protocol. The mandatory second opinion policy was associated with a small but significant reduction in rates of caesarean section (relative rate reduction 7.3%; 95% CI.0.2–14.5), mostly in intrapartum sections (12.6%; 0.6–24.7). Other maternal and neonatal outcomes and women's perceptions and satisfaction with the process of care were similarly distributed between the groups. Interpretation In hospitals applying this policy of second opinion, 22 intrapartum caesarean sections could be prevented per 1000 deliveries, without affecting maternal or perinatal morbidity, and without affecting mothers' satisfaction with the care process.