WHO ACTION-I trial
A trial in 29 hospitals in Bangladesh, India, Kenya, Nigeria and Pakistan. Pregnant women who were likely to give birth early received either a dexamethasone steroid injection or a dummy injection, to see whether the steroid lowered newborn deaths. The trial stopped early because deaths among the babies were lower in the dexamethasone group.
Also called ACTION-I · WHO ACTION-I Trial
- Study
- In this atlas
Overview
- Design
- Multicountry, multicentre, individually randomized (1:1, site-stratified), parallel-group, double-blind, placebo-controlled trial of intramuscular dexamethasone against identical placebo, given to women at risk of imminent preterm birth in 29 secondary- and tertiary-level hospitals. Women were randomized from December 2017 through November 2019. The sources describe the block design differently, and this is not reconciled: the manuscript says "balanced permuted blocks of size 10", while the CTRI record read through ICTRP describes permuted blocks of variable size.
- Phase
- Phase 3
- Enrolled
- 2,852 women
- 3,070 fetuses
- 6,018 women (ANZCTR target sample size)
- 6,120 participants (CTRI target sample size via ICTRP; the unit is not named)
- 2,852 participants (ANZCTR final sample size under accrual; the unit is not named)
- Sponsor
- Registry
-
ACTRN12617000476336 -
CTRI/2017/04/008326
-
- Results reported in
- Started
- (actual)
- Primary completion
- Not reported
- Completion
- Not reported
- Countries
- Bangladesh, India, Kenya, Nigeria, Pakistan
- Care setting
- Hospital-based care at 29 secondary- and tertiary-level hospitals across six study sites. The hospitals were chosen after a standard assessment so that the WHO conditions for antenatal corticosteroid use could reasonably be met.
- Registry status
- “Stopped early”
- “Completed”
- Stopped early
- Enrollment stopped early, . After the second interim analysis the data safety monitoring board recommended stopping the trial for benefit on infant mortality, and recruitment stopped at all sites on this date. ANZCTR records the status as stopped early; the CTRI record, read through ICTRP, says completed.
Technical summary
Multicountry, multicentre, individually randomized, parallel-group, double-blind, placebo-controlled trial (ACTRN12617000476336; CTRI/2017/04/008326). 2852 women and their 3070 fetuses were randomized; registry targets were 6018 (ANZCTR) and 6120 (CTRI, via ICTRP). Entry: gestational age 26 weeks 0 days to 33 weeks 6 days with birth planned or expected within 48 hours. Intramuscular dexamethasone 6 mg every 12 hours for up to four doses against identical placebo. Primary outcomes: neonatal death, stillbirth or neonatal death, and possible maternal bacterial infection, tested for non-inferiority with a margin of 1.25 on the relative scale. The data safety monitoring board recommended stopping after the second interim analysis, and recruitment stopped on 21 November 2019. The registries differ on first enrolment: the ICTRP view of the CTRI record lists 2017-06-01 (read as day-month-year), the same date as ANZCTR's anticipated first enrolment, while ANZCTR's actual first enrolment is 2017-12-24 and the manuscript says women were randomized from December 2017. Sponsor: WHO. The manuscript names the Gates Foundation as primary funder with additional support from WHO departments; the PubMed abstract credits both.
Arms
-
Dexamethasone (intervention)
Intervention Antenatal corticosteroids
Intramuscular dexamethasone 6 mg given to the woman every 12 hours, up to four doses or until hospital discharge or birth. A repeat course with the same allocation was allowed if she had not given birth after seven completed days and still met the inclusion criteria.
-
Identical placebo (control)
Intervention
Identical placebo (normal saline per ANZCTR) on the same schedule as dexamethasone, with the same repeat-course rule.
Findings
Findings are grouped by the claim they support. Each group keeps its own population and follow-up, and each finding keeps its own denominator and time window. Not reported is not zero, and findings from different contexts are not combined.
In plain words
In the ACTION-I trial, pregnant women at risk of imminent preterm birth, from 26 weeks 0 days to 33 weeks 6 days of pregnancy, received either dexamethasone or a dummy injection. Fewer of their liveborn babies died in the first 28 days of life in the dexamethasone group: 278 of 1417 (19.6%) against 331 of 1406 (23.5%) in the placebo group (relative risk 0.84, 95% CI 0.72 to 0.97). The medicine was given to the mother, and the outcome counted here is the baby's.
- Liveborn infants of the randomized women. The window of 26 weeks 0 days to 33 weeks 6 days is the mother's gestational age when she entered the trial. It does not limit the infant's gestational age at birth, and the research gives no such limit. Birth occurred before 37 weeks for 90.0% of infants in the dexamethasone group and 90.8% of infants in the placebo group.
- Hospital-based: 29 secondary- and tertiary-level hospitals across six study sites. The hospitals were chosen after a standard assessment so that the WHO conditions for antenatal corticosteroid use could reasonably be met.
- Bangladesh, India, Kenya, Nigeria and Pakistan
- Neonatal period, birth to 28 days
- Gestational age Not reported
- Postnatal age 0 days to 0 days
Neonatal death, birth to 28 completed days Primary endpoint
278 of 1,417 infants in the Dexamethasone (intervention) arm
- Measure
- Liveborn infants who died by 28 completed days of life (count)
- Value
- 278 infants
- Reported as
- 278/1417 (19.6)
- Interval
- Not applicable
- Denominator
- n = 1,417
- Time window
- Birth to 28 completed days of life
331 of 1,406 infants in the Identical placebo (control) arm
- Measure
- Liveborn infants who died by 28 completed days of life (count)
- Value
- 331 infants
- Reported as
- 331/1406 (23.5)
- Interval
- Not applicable
- Denominator
- n = 1,406
- Time window
- Birth to 28 completed days of life
Dexamethasone (intervention) compared with Identical placebo (control)
- Measure
- Relative risk, dexamethasone vs placebo, modelled with adjustment for study site and for clustering from multiple births (Table 2 footnote)
- Value
- 0.84 ratio
- Reported as
- 0.84 (0.72-0.97)
- Interval
- 0.72 to 0.97
- Denominator
- Not applicable
- Time window
- Birth to 28 completed days of life
Caveats
Limitations. One placebo-controlled trial in 29 secondary- and tertiary-level hospitals in five low-resource countries. The hospitals were chosen so that the WHO conditions for steroid use could reasonably be met, so the result does not describe lower-level facilities or the community. The trial stopped early for benefit, short of its planned sample. About 90% of the infants were born before 37 weeks. The authors report that 45% of women received fewer than four doses, and name the difficulty of standardizing care across sites and the use of third-trimester ultrasound to confirm gestational age for many participants as limits. The relative risk is model-based, adjusted for site and for multiple births, with intervals adjusted for multiplicity. Figures come from the PubMed abstract and the Author Final Manuscript; the version of record was not fetched (HTTP 403) and the figures were not checked against it.
Sources and citations (6)
-
Supports Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries
- Locator
- Abstract, RESULTS, sentence 3
- How it applies
- Abstract of the primary report; the same infants and time window as this context.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
adb2579c89c865461eb3f3ace681a011868a4f43b15a028d7178d08ad0d7057e- Reuse basis
- Bibliographic metadata and short factual extraction. The PMC Author Final Manuscript states that it is licensed for use under the CC BY license and is committed at research/snapshots/ma-pmc-PMC7660991.xml. Attribution: WHO ACTION Trials Collaborators, N Engl J Med 2020;383:2514-2525, doi:10.1056/NEJMoa2022398, Author Final Manuscript via PMC (PMC7660991). The version of record is not redistributed.
-
Supports Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries
- Locator
- Table 2, row Neonatal death
- How it applies
- Author Final Manuscript (CC BY); not checked against the version of record.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
8c795f040d84bf82311862509bdde4ea0f243d2933f596c1bd4f80ebdae14b26- Reuse basis
- Bibliographic metadata and short factual extraction. The PMC Author Final Manuscript states that it is licensed for use under the CC BY license and is committed at research/snapshots/ma-pmc-PMC7660991.xml. Attribution: WHO ACTION Trials Collaborators, N Engl J Med 2020;383:2514-2525, doi:10.1056/NEJMoa2022398, Author Final Manuscript via PMC (PMC7660991). The version of record is not redistributed.
-
Background Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries
- Locator
- Table 2, footnote
- How it applies
- The relative risk is modelled and the intervals are adjusted for multiplicity.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
8c795f040d84bf82311862509bdde4ea0f243d2933f596c1bd4f80ebdae14b26- Reuse basis
- Bibliographic metadata and short factual extraction. The PMC Author Final Manuscript states that it is licensed for use under the CC BY license and is committed at research/snapshots/ma-pmc-PMC7660991.xml. Attribution: WHO ACTION Trials Collaborators, N Engl J Med 2020;383:2514-2525, doi:10.1056/NEJMoa2022398, Author Final Manuscript via PMC (PMC7660991). The version of record is not redistributed.
-
Background Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries
- Locator
- Methods, Study outcomes, para 1
- How it applies
- Defines neonatal death for this trial.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
8c795f040d84bf82311862509bdde4ea0f243d2933f596c1bd4f80ebdae14b26- Reuse basis
- Bibliographic metadata and short factual extraction. The PMC Author Final Manuscript states that it is licensed for use under the CC BY license and is committed at research/snapshots/ma-pmc-PMC7660991.xml. Attribution: WHO ACTION Trials Collaborators, N Engl J Med 2020;383:2514-2525, doi:10.1056/NEJMoa2022398, Author Final Manuscript via PMC (PMC7660991). The version of record is not redistributed.
-
Background Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries
- Locator
- Discussion, para 1
- How it applies
- The benefit was seen even though many women received fewer than four doses.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
8c795f040d84bf82311862509bdde4ea0f243d2933f596c1bd4f80ebdae14b26- Reuse basis
- Bibliographic metadata and short factual extraction. The PMC Author Final Manuscript states that it is licensed for use under the CC BY license and is committed at research/snapshots/ma-pmc-PMC7660991.xml. Attribution: WHO ACTION Trials Collaborators, N Engl J Med 2020;383:2514-2525, doi:10.1056/NEJMoa2022398, Author Final Manuscript via PMC (PMC7660991). The version of record is not redistributed.
-
Background Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries
- Locator
- Methods, Study setting, para 1
- How it applies
- Hospitals were selected so that the WHO treatment criteria could reasonably be met.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
8c795f040d84bf82311862509bdde4ea0f243d2933f596c1bd4f80ebdae14b26- Reuse basis
- Bibliographic metadata and short factual extraction. The PMC Author Final Manuscript states that it is licensed for use under the CC BY license and is committed at research/snapshots/ma-pmc-PMC7660991.xml. Attribution: WHO ACTION Trials Collaborators, N Engl J Med 2020;383:2514-2525, doi:10.1056/NEJMoa2022398, Author Final Manuscript via PMC (PMC7660991). The version of record is not redistributed.
Claims and evidence
Context Pregnant women at risk of imminent preterm birth at 26w0d to 33w6d, in 29 hospitals in five low-resource countries (ACTION-I)
- Recipient
- Maternal
- Population
- Pregnant women with a confirmed live fetus, single or multiple pregnancy, who were at risk of preterm birth between 26 weeks 0 days and 33 weeks 6 days of gestation and whose birth was planned or expected within 48 hours. Gestational age came from the earliest ultrasound or one done at admission.
- Care setting
- Hospital-based: 29 secondary- and tertiary-level hospitals across six study sites. The hospitals were chosen after a standard assessment so that the WHO conditions for antenatal corticosteroid use could reasonably be met.
- Geography
- Bangladesh, India, Kenya, Nigeria and Pakistan
- Life stage
- Pregnancy, from randomization to birth, with maternal infection followed to 28 days after birth
- Gestational age
- 26 weeks 0 days (182 days) to 33 weeks 6 days (237 days)
- Postnatal age
- Not reported
- Follow-up
- The maternal primary outcome, possible maternal bacterial infection, ran from randomization to 28 days postpartum and was captured during hospital admission only.
Eligibility: 4 inclusion criteria; 7 exclusion criteria
- Included
- Live fetus, single or multiple pregnancy
- Gestational age 26 weeks 0 days to 33 weeks 6 days
- Birth planned or expected in the next 48 hours
- Written informed consent before randomization
- Excluded
- Clinical signs of severe infection
- Major congenital fetal anomalies
- Systemic glucocorticoid use now or within the past two weeks
- Participation in another trial
- Contraindication to steroids
- Clinical suspicion or evidence of chorioamnionitis (registry criteria only; the paper lists clinical signs of severe infection)
- No earlier ultrasound estimate of gestational age and an immediate ultrasound not possible (registry criteria only; both ANZCTR and CTRI via ICTRP list it, and the paper says gestational age came from the earliest ultrasound or one done at admission)
ACTION-I stopped recruiting women early. After the second interim analysis the data safety monitoring board recommended stopping the trial because deaths among infants were lower with dexamethasone, and recruitment stopped at all sites on 21 November 2019. The two registries disagree on the trial's status: ANZCTR records it as stopped early and the CTRI record, read through WHO ICTRP, as completed.
Source problem. A cited source is unknown, not verified. Check the sources before relying on this claim.
Applies to Maternal- Pregnant women with a confirmed live fetus, single or multiple pregnancy, who were at risk of preterm birth between 26 weeks 0 days and 33 weeks 6 days of gestation and whose birth was planned or expected within 48 hours. Gestational age came from the earliest ultrasound or one done at admission.
- Hospital-based: 29 secondary- and tertiary-level hospitals across six study sites. The hospitals were chosen after a standard assessment so that the WHO conditions for antenatal corticosteroid use could reasonably be met.
- Bangladesh, India, Kenya, Nigeria and Pakistan
- Pregnancy, from randomization to birth, with maternal infection followed to 28 days after birth
- Gestational age 26 weeks 0 days to 33 weeks 6 days
- Postnatal age Not reported
- Certainty method
- Not assessed
- Limitations
- The registry disagreement is recorded, not reconciled. The CTRI view is a WHO ICTRP mirror refreshed in November 2021, and the primary CTRI record could not be read.
- Last checked
- Not recorded
- Next evidence check due
- Not scheduled
Sources and citations (5)
-
Supports Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries
- Locator
- Abstract, RESULTS, sentence 2
- How it applies
- Abstract of the primary report.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
adb2579c89c865461eb3f3ace681a011868a4f43b15a028d7178d08ad0d7057e- Reuse basis
- Bibliographic metadata and short factual extraction. The PMC Author Final Manuscript states that it is licensed for use under the CC BY license and is committed at research/snapshots/ma-pmc-PMC7660991.xml. Attribution: WHO ACTION Trials Collaborators, N Engl J Med 2020;383:2514-2525, doi:10.1056/NEJMoa2022398, Author Final Manuscript via PMC (PMC7660991). The version of record is not redistributed.
-
Supports Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries
- Locator
- Methods, Statistical analysis, para 3: board recommendation
- How it applies
- Author Final Manuscript (CC BY); not checked against the version of record.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
8c795f040d84bf82311862509bdde4ea0f243d2933f596c1bd4f80ebdae14b26- Reuse basis
- Bibliographic metadata and short factual extraction. The PMC Author Final Manuscript states that it is licensed for use under the CC BY license and is committed at research/snapshots/ma-pmc-PMC7660991.xml. Attribution: WHO ACTION Trials Collaborators, N Engl J Med 2020;383:2514-2525, doi:10.1056/NEJMoa2022398, Author Final Manuscript via PMC (PMC7660991). The version of record is not redistributed.
-
Supports Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries
- Locator
- Methods, Statistical analysis, para 3: recruitment stop
- How it applies
- Author Final Manuscript (CC BY); not checked against the version of record.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
8c795f040d84bf82311862509bdde4ea0f243d2933f596c1bd4f80ebdae14b26- Reuse basis
- Bibliographic metadata and short factual extraction. The PMC Author Final Manuscript states that it is licensed for use under the CC BY license and is committed at research/snapshots/ma-pmc-PMC7660991.xml. Attribution: WHO ACTION Trials Collaborators, N Engl J Med 2020;383:2514-2525, doi:10.1056/NEJMoa2022398, Author Final Manuscript via PMC (PMC7660991). The version of record is not redistributed.
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Supports The WHO ACTION-I (Antenatal CorticosTeroids for Improving Outcomes in preterm Newborns) Trial
- Locator
- Recruitment, Reason for early stopping
- How it applies
- ANZCTR record as last updated 2021-03-22.
- Retrieved
- Source effective date
- 2021-03-22
- Source state
- Current
- Snapshot hash
d43f7def2bdadf8c303488d8b03f6500f3786ed227e6232872ca447906b69d98- Reuse basis
- Short factual extraction. The page states that all rights are reserved and lists personal contact data, so its bytes were not saved. Public text is cite_only (fact-check decision of 2026-10-13): the page states all rights reserved, so public pages state the facts in the atlas's own words, with a citation and a link. Numbers and dates still bind through the quote table.
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Opposes Improving newborn survival in preterm birth
- Locator
- Main record fields
- How it applies
- ICTRP mirror of CTRI gives the status as completed.
- Retrieved
- Source effective date
- 2021-11-24
- Source state
- Unknown, not verified
- Snapshot hash
f80b7fcc0c2ca4a7ed56c92219e38fce42bacec3a4baef8335ed9806e6635485- Reuse basis
- Short factual extraction from the ICTRP mirror, not the primary register. The page lists personal contact data, so its bytes were not saved. Public text is cite_only (fact-check decision of 2026-10-13): the terms of the CTRI record, read through the WHO ICTRP mirror, are unverified, so public pages state the facts in the atlas's own words, with a citation and a link. Numbers and dates still bind through the quote table.
Record details
- Record id
maternal:action-i-trial- Content hash
2345b168518236d31f82d933ef4083442a3a46c7af8f85b02df3088bf83ebc48