Antenatal corticosteroids are currently used excessively and more stringent controls on their use should be established: <scp>AGAINST</scp>: Current use of antenatal corticosteroids effectively reduces neonatal morbidity and mortality

What would happen if more stringent controls were imposed on the administration of antenatal corticosteroids (ACS)? The rate of eligible women receiving ACS would undoubtedly decline, undoing progress that has taken decades to achieve. Although Liggins and Howie (Pediatrics 1972;50:515–25) demonstrated that ACS significantly reduced neonatal respiratory distress syndrome in 1972, this intervention did not gain immediate widespread clinical acceptance. It was only after a 1994 recommendation from the National Institute of Child Health and Human Development to administer ACS in the setting of threatened preterm birth (NIH Consensus Statement 1994;12:1–24) that use of ACS became routine clinical practice. Despite the known benefits of ACS, including reduction of not only neonatal respiratory distress syndrome but also necrotising enterocolitis, intraventricular haemorrhage and overall mortality, the rate of administration remains suboptimal. A study from 2014 reviewed preterm deliveries from 2009 to 2011 at a tertiary care centre in the USA and found that before delivery, only 69.6% of eligible women received both doses of ACS (Chandrasekaran and Srinivas Am J Obstet Gynecol 2014;210:143.e1–7). In 2015, a study from Canada reviewed an administrative database of live births from 1988 to 2012 to assess rates of ACS administration and found an underuse of ACS at 33–34 weeks of gestation (Razaz et al. Obstet Gynecol 2015;125:288–96). Although current practice patterns may be trending towards improvement, this is not enough. Every neonate born before 34 weeks should receive a course of ACS. For many causes of preterm birth it is difficult to determine the best time to administer ACS. A study of a single tertiary-care centre in the USA reviewed preterm births from 2006 to 2011 and found that while 93% of eligible women received ACS, optimal timing occurred in only 40.4% of them (Levin et al. BJOG 2016;123:409–14). Specifically, optimal timing occurred in 36.3% of women with symptomatic preterm contractions, 46.2% of women with preterm premature rupture of membranes, 62.1% of women with hypertensive disorders of pregnancy and 20.6% of women with placental abruption/bleeding. Given that our ability to determine who will deliver preterm and when is poor, the choice is between administering steroids when there is concern for preterm birth—knowing that some women will receive ACS who do not need them—and withholding steroids until the probability of preterm birth is very high and increasing the proportion of preterm births where steroids are not administered. Given our current state of knowledge, it is unlikely that more stringent controls on ACS administration would provide any benefit. Ultimately what would improve care are better tools to predict preterm birth. Being better able to anticipate when women will deliver is the only way that the rate of proper steroid administration can be increased, while decreasing unnecessary administration. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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