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  • More than million almost children younger than


    More than 200 million—almost 40%—children younger than 5 years in developing countries are not fulfilling their developmental potential. In parts of Africa, up to three-quarters of children are victims of physical abuse, and a third of girls and more than 10% of boys are victims of sexual abuse. One study in 21 high-income, middle-income, and low-income countries showed that adversities such as child maltreatment and several risk factors for poor early child development were highly prevalent (around 40%), tended to co-occur, and accounted for 29·8% of mental disorders in later life. There is substantial, and frequently unacknowledged, overlap between early child development and prevention interventions for violence against children. Programmes for early child development and prevention of violence against children frequently include the same interventions—eg, parenting interventions. Some of the main efforts to prevent violence against children, such as home visit programmes, also target various early child development outcomes.
    In their Comment (April issue), Kishwar Azad and Anthony Costello raise questions that should be answered before antenatal corticosteroid treatment is scaled up to reduce preterm deaths in low-income countries. We share their concerns about the unknown overall effect of this Microcystin-LR cost treatment on mortality and potential safety issues in the mother. To answer these questions, we have initiated the Antenatal Corticosteroids Trial to assess whether or not a multifaceted intervention to increase the use of antenatal corticosteroids reduces neonatal mortality at 28 days of age, and maternal morbidity due to infections. Enrolment has been completed and data from more than 90 000 births have been collected. We disagree with Azad and Costello\'s comment about the effect of antenatal corticosteroid treatment on respiratory distress in infants at 34 weeks\' gestation. This statement is based on a subgroup analysis from a systematic review. However, the same review presents data showing a decreased risk of respiratory distress syndrome in infants with first dose of corticosteroids administered to mothers at 33–35 weeks\' gestation (relative risk [RR] 0·53, 95% CI 0·31–0·91), and a non-significant decrease in the risk of respiratory distress in infants (0·61, 0·11–3·26) with first dose at 35–37 weeks\' gestation. The findings suggest a reduction in respiratory distress syndrome is present according to gestational age at first delivery of corticosteroids. Prevention of respiratory distress syndrome in infants born at 33–36 weeks\' gestation without access to specialised high-quality level 2 care might create a substantial health-care burden in low-income countries. The Antenatal Corticosteroids Trial will assess the administration of steroids to mothers up to 36 weeks\' gestation. Data from this trial will be available in the second half of 2014. We hope that several of the concerns expressed in the Comment by Azad and Costello will be addressed.
    The Comment by Kishwar Azad and Anthony Costello opposing scale-up of antenatal corticosteroids misdirects the discussion of this topic towards speculation about differences in low-income settings. Our experience in Malawi provides a concrete example of the rapid scaling up of antenatal corticosteroid treatment with dexamethasone. Malawi has the highest estimated preterm birth rate worldwide. In Bwaila Maternity Hospital, Lilongwe, that has more than 15 000 deliveries annually with more than 2900 preterm, we increased targeted coverage of antenatal corticosteroids from 8% to 80% in 16 weeks in women at risk of preterm delivery from 24 to 34 weeks\' gestation. After this pilot study, we began programmes in three other hospitals, reaching 59–83% coverage from a baseline of 1–6% within 6 weeks. This intervention has thus far been associated with a drop in preterm neonatal mortality contribution from 60% to 24% at 0–6 days of age. Although this intervention was not done as part of a trial, and focuses only on quality improvement, we noted no increase in the rate of maternal or neonatal infections.