Abstract
Objective:
To describe the intrapartum and postpartum use of non-study antibiotics in low- and middle-income countries (LMICs) during the double-blinded NICHD Global Network Azithromycin in Labor (A-PLUS) Trial.
Design:
The antibiotic use sub-study was a planned prospective, observational sub-study of the A-PLUS Trial.
Settings:
The study was carried out in hospitals or health centers affiliated with 8 sites of the Global Network for Women’s and Children’s Health Research (Global Network) in 7 countries: Bangladesh, Pakistan, India (2 sites), Kenya, Zambia, The Democratic Republic of the Congo (DRC) and Guatemala.
Population:
29,278 pregnant women enrolled in the A-PLUS Trial
Methods:
We collected data on 29,278 pregnant women admitted to a facility for delivery related to non-study antibiotic use overall and during three time-periods: 1) in the facility prior to delivery, 2) after delivery until facility discharge and 3) after discharge to 42 days post-partum.
Main outcome measures:
Non-study antibiotic use overall and for treatment or prophylaxis by site during the three time-periods
Results:
Of the 29,278 women in the study, 5,020 (17.1%; 95% CI 16.7%-17.6%) received non-study antibiotics in the facility prior to delivery, 11,956 (40.8%; 95% CI 40.3%-41.4%) received non-study antibiotics in the facility after delivery, and 13,390 (47.6%; 95% CI 47.0%-48.2%) women received non-study antibiotics after delivery and after facility discharge. Antibiotics were prescribed more often among women in the Asian and Guatemalan sites than in the African sites. In the three time-periods, among those receiving antibiotics, prophylaxis was the indication in 82.3%, 97.7% and 90.7% of the cases, respectively. The type of antibiotics used varied substantially by time-period and site, but generally, penicillin-type drugs, cephalosporin-type drugs and metronidazole were used more frequently than other types.
Conclusions:
Across the 8 sites of the Global Network, in the facility before delivery, and in the post-partum periods before and after facility discharge, antibiotics were used frequently, but use was highly variable by site and time-period.
Funding:
This study was funded by grants from NICHD and the Bill & Melinda Gates Foundation.
Keywords: maternal antibiotics, low- and middle-income countries, pregnancy, infection, A-PLUS Trial
Summary/Tweetable abstract:
Around delivery, antibiotics were prescribed to large numbers of women, mostly for prophylaxis.
Introduction
Maternal sepsis remains an important cause of maternal mortality and morbidity. The use of antimicrobials has transformed medicine, likely saving millions of lives.(1-5) However, antibiotic use is a significant factor in the emergence of antimicrobial resistance (AMR), particularly in low- and middle-income countries (LMICs), and is considered one of the most important global public health threats. (6,7)
Medication use during pregnancy requires careful evaluation of risks and benefits. (6,8) Prophylactic use of antibiotics to reduce infection in women undergoing cesarean delivery, and select other conditions, has shown benefit. (9-14) As an example, Knight and colleagues studied 3,427 women randomized to amoxicillin and clavulanic acid or placebo within 6 hours of operative vaginal delivery. (15) The primary outcome, confirmed or suspected maternal infection within 6 weeks of delivery, was significantly less common in the antibiotic (11%) versus the placebo (19%) group (risk ratio [RR] 0·58, 95% CI 0·49–0·69).
In the US and European countries, nearly half of women receiving antibiotics during pregnancy.(16-19) In LMICs, rates may be higher, with studies from India and Bangladesh showing about 90% of all peri-partum women administered antibiotics (20, 21) and half in Indonesia. (22) Similar increases are seen in rural and urban areas of LMICs. For example, in rural Ghana, antibiotic use in pregnancy increased from 55% in 2013 to 78% in 2015. (23)
Widespread antibiotic use among pregnant women potentiates AMR in pathogens, especially those causing maternal sepsis in LMICs. (6,7) Factors contributing to high rates of LMIC antibiotic use include insufficient awareness of risks of antibiotic overuse, inadequate regulatory frameworks, deficient healthcare infrastructure, and lack of adherence to guidelines.
Globally, several initiatives have sought to curb injudicious antibiotics use, including the World Health Organization (WHO) Antimicrobial Stewardship Program (AMS)(24,25). WHO also provides guidelines on the prevention of peri-partum infections, antimicrobial agents, and antibiotic prophylaxis for preventing infection during cesarean delivery.(26,27) In addition, many countries have introduced guidelines on antibiotic use.(28) However, guidelines for prophylactic antibiotic use around delivery in LMICs are often not well operationalized.(29-32)
Our objective was to describe the frequency and types of non-study antibiotics used during labor and in the postpartum periods in LMICs. (33) The A-PLUS Trial evaluated azithromycin in labor and collected information on non-study antibiotic use without changing clinical practice.(34,35) We quantified non-study antibiotics and indications for use (treatment or prophylaxis), the class of antibiotics used, and timing.
Methods
This was a planned secondary analysis of the A-PLUS randomized controlled trial of a single dose of azithromycin to prevent maternal death and sepsis and fetal and neonatal death and sepsis in LMICs. This study was performed in the eight sites of Global Network for Women’s and Children’s Health Research from 2020 to 2022. (33,34) These sites are located in Bangladesh, India (2 sites), Pakistan, Kenya, Zambia, the Democratic Republic of the Congo (DRC) and Guatemala. In this study, women in labor at ≥ 28 weeks’ gestation who were planning a vaginal delivery were randomized to receive a single intrapartum 2 gm oral dose of azithromycin or an identically appearing placebo. Women who had a known infection requiring antibiotics or who had received azithromycin or other macrolides within 3 days of delivery were excluded. The two primary outcomes for the trial were 1) a composite of maternal sepsis or death, and 2) a composite of stillbirth or neonatal death or sepsis. Details of this study and the results of the randomized trial have been reported. (34,35) In summary, the women who received azithromycin had less sepsis or death or any infection (driven mostly by less sepsis), while there was not a significant impact of maternal administration of azithromycin during labor on fetal or neonatal infections.
In addition, we collected data on non-study antibiotic use 1) by the laboring mother from enrollment to before delivery, and 2) for both the mother and infant after delivery prior to facility discharge and 3) after discharge until day 42. For this report, we analyzed data on antibiotic use by 29,278 mothers who participated in the A-PLUS Trial. Use of non-study antibiotics was categorized by site and whether the use was for treatment of an infection or given for prophylaxis. Use was defined as treatment if the antibiotic was given for treatment of an existing or suspected infection or for another indication and prophylaxis if the antibiotic was given with a goal to prevent an infection. Treatment or prophylaxis was determined by the study staff after review of the medical record or discussion with the physician or subject.
Because many different antibiotics were used, we classified the non-study antibiotics into 4 categories: 1) penicillin-like drugs such as penicillin and ampicillin, 2) the cephalosporins, 3) metronidazole, and 4) gentamicin. We generally present data on antibiotics that were used by more than one percent of the study participants. Azithromycin (other than as the study drug) was rarely used for either mothers or babies.
Our analytic approach included determining the frequency with 95% confidence intervals of non-study antibiotic use overall and by site. We calculated the overall proportion of women with antibiotic use for each time-period, i.e., prior to delivery, after delivery in the facility and after facility discharge until day 42. The relative risk (RR) and 95% confidence interval (CI) of non-study antibiotic use for each time-period comparing the azithromycin arm to the placebo arm was obtained by fitting a Poisson model adjusting for site and treatment arm.
Prior to our analysis, we considered whether the participants randomized to azithromycin may have had less non-study antibiotic use, since the use of azithromycin may have reduced infections and potentially less non-study antibiotics. We emphasize, however, that the results of the randomization were unknown during the trial when data on non-study antibiotic use was collected and for purpose of this descriptive analyses, we combined the results for both treatment groups. There were, however, small differences in non-study antibiotic use between the women who received azithromycin and placebo in the women after hospital discharge until day 42, and these results are shown in Figure 2.
Figure 2.
Maternal Non-Study Antibiotic Usage by Period and Site in Women Randomized to Azithromycin or Placebo
Ethics approvals
The A-PLUS trial protocol was reviewed and approved by the ethics review committees and institutional review boards at each participating study site, their partner US institutions and the data coordinating center (DCC) (see Declarations for detail). All participants provided informed written consent prior to participation in the trial.
Results
Of the 44,078 women originally screened for the A-PLUS trial, 29,278 women were eligible and consented to participate in the trial. The reasons for the exclusions are shown (Figure S1). Among women considered for enrollment in A-PLUS, only 328 women were excluded because of antibiotic use within the last 3 days. Of the 29,278 randomized mothers, 4,373 were from the DRC, 3,673 were from Kenya, 3,534 were from Zambia, 2,847 were from Bangladesh, 5,628 were from Belagavi, India, 3,958 were from Nagpur, India, 3,668 were from Pakistan and 1,597 were from Guatemala.
Table 1 provides a brief description of the study population including women from all sites. The median age was 24.0 years and 94.1% were married, 23.7% had no formal schooling and 50.1% had 7-12 years of schooling. Of the women, 43.3% were primiparous and 0.7% were having a multiple birth, 18.4% had a labor induction, 5.5% claimed to have had a maternal infection during this pregnancy, 6.7% had one of several maternal conditions, 4.7% were designated high-risk because of being in labor ≥18 hours before they were randomized, and 4.3% had ≥8 hours of membrane rupture before they were randomized. In this population, 12.8% of the women delivered at <37 weeks gestational age.
Table 1.
Characteristics of Participants
| Maternal Characteristics | Total Study Population (n=29,278) |
|---|---|
| Maternal age (years), Median (IQ range) | 24.0 (21.0, 28.0) |
| Married, n/N (%) | 27,563/29,276 (94.1) |
| Maternal education, n/N (%) | |
| No formal schooling | 6,933/29,230 (23.7) |
| 1 - 6 years of schooling | 4,024/29,230 (13.8) |
| 7 - 12 years of schooling | 14,633/29,230 (50.1) |
| ≥ 13 years of schooling | 3,640/29,230 (12.5) |
| Primiparous, n/N (%) | 12,687/29,275 (43.3) |
| Multiple birth, n/N (%) | 194/29,275 (0.7) |
| Labor induction, n/N (%) | 5,375/29,258 (18.4) |
| Any maternal infection during pregnancy1, n/N (%) | 1,618/29,276 (5.5) |
| Any maternal condition during pregnancy2, n/N (%) | 1,972/29,276 (6.7) |
| Prolonged labor ≥ 18 hours before randomization, n/N (%) | 1,368/29,275 (4.7) |
| Prolonged ROM ≥ 8 hours before randomization, n/N (%) | 1,247/29,275 (4.3) |
| Gestational age < 37 weeks, n/N (%) | 3,736/29,267 (12.8) |
Any maternal infection during pregnancy includes group B strep, pneumonia, pyelonephritis, rubella, chlamydia, herpes, syphilis, gonorrhea, HIV, hepatitis B, malaria, urinary tract infection or other infection.
Any maternal condition during pregnancy includes diabetes, chronic hypertension, hypertensive disorders of pregnancy or other condition.
Figure 1 shows the proportion of study mothers who received non-study antibiotics across the 8 sites of the Global Network including 1) those in labor in the facility prior to delivery, 2) those in the facility after delivery, and 3) and those who received antibiotics after facility discharge prior to day 42 postpartum. In each of the time-periods, antibiotic use varied substantially among the sites, but in general, use was lower in the African compared to the other sites. In the facility after delivery, in the two Indian sites, non-study antibiotic use approached 100%, with less use in the other sites. After facility discharge, overall, non-study antibiotic use was 82 - 93% in the Pakistani and the Indian sites, nearly 60% in Guatemala, but <20% in the African and Bangladeshi sites.
Figure 1.
Maternal Non-study Antibiotic Usage by Period and Site (n=29,278)
For each antibiotic, we asked the research staff to determine (by chart review or discussion with provider or subject) whether the antibiotics used were given for treatment or prophylaxis. In Table 2, first, the very large discrepancies in antibiotic use across the sites are apparent. In the African sites, prior to delivery, antibiotic use was rare and if used, antibiotics were often given for treatment. However, overall, in the other time-periods, and across all the sites, more than 80% of antibiotic use was for prophylaxis rather than for treatment. However, in Bangladesh after facility discharge, the majority of women who received antibiotic treatment were given antibiotics for treatment. And in the DRC, nearly 50% of those treated with antibiotics were given them for treatment. In the other sites, 90% or more of those treated with antibiotics were given the antibiotics for prophylaxis. The data related to treatment vs prophylaxis by site and type of antibiotic are shown pictorially (Figures S2, S3 and S4) with the percent of prophylactic use for each antibiotic shown in blue.
Table 2.
Antibiotics Given to the Mother by Site for Prophylaxis or Treatment in the 3 Periods
| Africa | Asia | Latin America |
|||||||
|---|---|---|---|---|---|---|---|---|---|
| Overall | DRC | Kenya | Zambia | Bangladesh | Belagavi, India |
Nagpur, India |
Pakistan | Guatemala | |
| Randomized, n | 29,278 | 4,373 | 3,673 | 3,534 | 2,847 | 5,628 | 3,958 | 3,668 | 1,597 |
| Antibiotics in facility prior to delivery, n % (95% CI) | 5,020 17.1% (16.7, 17.6) |
30.1% (0.0, 0.1) |
40.1% (0.0, 0.2) |
30.1% (0.0, 0.2) |
645 22.7% (21.1, 24.2) |
1,745 31.0% (29.8, 32.2) |
1,229 31.1% (29.6, 32.5) |
743 20.3% (19.0, 21.6) |
648 40.6% (38.2, 43.0) |
| Prophylaxis, n (%) | 4,080 (82.3) |
1 (33.3) |
0 (0.0) |
1 (100.0) |
401 (62.2) |
1,612 (93.7) |
889 (73.7) |
562 (75.7) |
614 (96.8) |
| Treatment, n (%) | 875 (17.7) |
2 (66.7) |
3 (100.0) |
0 (0.0) |
244 (37.8) |
108 (6.3) |
318 (26.3) |
180 (24.3) |
20 (3.2) |
| Antibiotics in facility after delivery, n % (95% CI) | 11,956 40.8% (40.3, 41.4) |
143 3.3% (2.7, 3.8) |
200 5.4% (4.7, 6.2) |
301 8.5% (7.6, 9.4) |
264 9.3% (8.2, 10.3) |
5,567 98.9% (98.6, 99.2) |
3,922 99.1% (98.8, 99.4) |
847 23.1% (21.7, 24.5) |
712 44.6% (42.1, 47.0) |
| Prophylaxis, n (%) | 11,667 (97.7) |
104 (73.2) |
195 (98.0) |
299 (99.3) |
151 (57.6) |
5,531 (99.4) |
3,872 (98.8) |
832 (98.3) |
683 (97.2) |
| Treatment, n (%) | 271 (2.3) |
38 (26.8) |
4 (2.0) |
2 (0.7) |
111 (42.4) |
33 (0.6) |
49 (1.2) |
14 (1.7) |
20 (2.8) |
| Antibiotics after discharge, n % (95% CI) | 13,930 47.6% (47.0, 48.2) |
507 11.6% (10.6, 12.5) |
221 6.0% (5.2, 6.8) |
302 8.5% (7.6, 9.5) |
464 16.3% (14.9, 17.7) |
4,862 86.4% (85.5, 87.3) |
3,261 82.4% (81.2, 83.6) |
3,404 92.8% (92.0, 93.6) |
909 56.9% (54.5, 59.3) |
| Prophylaxis, n (%) | 12,493 (90.7) |
280 (55.3) |
198 (90.0) |
271 (90.0) |
138 (43.1) |
4,522 (93.0) |
3,059 (93.8) |
3,152 (92.6) |
873 (96.0) |
| Treatment, n (%) | 1,288 (9.3) |
226 (44.7) |
22 (10.0) |
30 (10.0) |
182 (56.9) |
339 (7.0) |
202 (6.2) |
251 (7.4) |
36 (4.0) |
Note: Indication is defined as treatment if at least one antibiotic was given for treatment of infection or other reason and prophylaxis if all antibiotics were given for prophylaxis.
We also wanted to determine the type of antibiotics used in each site by time-period as categorized into 1) penicillins, 2) cephalosporins, 3) metronidazole, and 4) gentamicin. Prior to delivery, 5,020 of the 29,278 women (17.1%; 95% CI 16.7%-17.6%) received an antibiotic. (Figure S2) Of these 5,020 women, cephalosporins were used in 4077 (81.2%) women; metronidazole was used in 1194 (23.8%) women, and antibiotics from the penicillin group were used in 886 (17.6 %) women. Supplemental Figure 2 displays the use of different antibiotics groups prior to delivery in each site. In Bangladesh, the most common antibiotics were from the penicillin group, while in India, Pakistan and Guatemala, the most common antibiotics were from the cephalosporin group. The Bangladeshi and the Indian sites had some use of metronidazole prior to delivery.
Overall, after delivery, in the facility, 11,956 of the 29,278 (40.8%; 95% CI 40.3%-41.4%) women received an antibiotic. Cephalosporins were used in 8,088 (67.6%) of the women who received an antibiotic after delivery. Metronidazole was used in 8,051 (67.3%) of the women who received an antibiotic. Antibiotics in the penicillin group were used in 3,208 (26.8 %) women and gentamicin was used in 415 (3.5%) women.
Figure S3 displays the antibiotics used in the facility after delivery by site. Overall, antibiotics were used less frequently in the African sites as compared to the Asian and Guatemalan sites. Among the 11,956 women who were prescribed an antibiotic, the penicillin group was used far less in all the sites except Nagpur (52.5%). The cephalosporin group was the most common group used and largely by the Asian and Guatemalan sites. Metronidazole was mostly used in the Indian sites.
During follow-up after discharge until day 42 after birth, 13,930 (47.6%; 95% CI 47.0%-48.2%) women received a non-study antibiotic. Cephalosporins were used in 6,759/13,930 (48.5%) of the women who received an antibiotic. Metronidazole was used in 7,414 (53.2%) women. Antibiotics of the penicillin group were used in 5,970 (42.9%) women and gentamicin was used in 288 (2.1%) women. Figure S4 displays the type of antibiotics used after discharge from the facility by site. Of those 13,930 women who were given an antibiotic, the penicillin group was mostly used by the Nagpur, Pakistan and Guatemalan sites. Except for Bangladesh, antibiotics of the cephalosporin group were largely used by the Asian sites, as was metronidazole. Gentamicin was rarely used after facility discharge in any of the sites.
There were no significant differences in non-study antibiotic use between the women randomized to azithromycin and placebo in the period prior to delivery (RR 1.00; 95% CI 0.95-1.06) or after delivery prior to facility discharge (RR 0.99; 95% CI 0.96-1.03). There were, however, consistent small (but not significant) differences in non-study antibiotic use during follow-up after facility discharge (RR 0.97; 95% CI 0.94-1.00) with the decrease favoring the women treated with azithromycin. Figure 2 demonstrates these differences by site. The small differences in use between the groups appear to be related to differences in use for treatment rather than for prophylaxis.
Discussion
Main Findings
This study evaluated non-study antibiotic use during a randomized placebo-controlled trial of azithromycin given during labor to reduce maternal sepsis and death and fetal and neonatal sepsis and death. (34,35) We emphasize that since the original study was double-blinded, during the study, none of the subjects or study staff knew whether the subjects had received azithromycin or the placebo. There were small differences in non-study antibiotic use between the treatment and placebo groups in the women after discharge, but this observation does not distract from the overall conclusion regarding the high volume of non-study antibiotic use and the wide variability in non-study antibiotic use by site.
The first major observation is that the use of non-study antibiotics was highly variable among the sites and among the three time-periods. Antibiotics were given to nearly 100% of the subjects after delivery in the facilities in India, with less use in the other sites and in the other time-periods. Most antibiotic use in all time-periods was for prophylaxis (>80%), not treatment. Regardless of time or indication, cephalosporins, penicillin and metronidazole were the most frequently used antibiotics.
While much has been written about the overuse of antibiotics and the risk of antimicrobial resistance with increasing antibiotic use, among pregnant women, it is far from settled which women, if any, will benefit from which antibiotics. Tita et al and others have shown that the use of azithromycin in women undergoing cesarean delivery reduces various types of infection, and in the parent A-PLUS study, azithromycin given during labor reduced the risk of the combined outcome of maternal sepsis and death, driven mostly by sepsis. (34-35) There was no improvement in any fetal or neonatal outcome after the mother received azithromycin, results similar to some but not all other azithromycin studies. (35,36) The outcomes to mothers, fetuses and neonates for use of other antibiotics are less clear.
In this study, although we have not compared the prophylactic use of antibiotics to any specific guidelines, we have documented a very high rate of their use and have also demonstrated a large variation in their use across all seven LMICs and in 3 intervals of peri-partum care. Our results agree with the reports of various studies on the high use of antibiotics, including in both high-income countries and in LMICs. (6,7) The high use of antibiotics for prophylaxis around delivery in our study, especially in the Asian sites, is especially a matter of concern.
Strengths and Limitations
The study has a number of strengths and some weaknesses. Among the strengths are the large number of participants, data from 7 countries, and the use of standard data collection instruments. Weaknesses include that we do not have information on the reasons for the use of antibiotics for prophylaxis and or treatment, and specifically why the sites designated usage as either for treatment or prophylaxis. Additionally, because the sample population only included a limited number of facilities in each country, our results are not necessarily representative of antibiotic use in each country.
Interpretation
Irrespective of these limitations, our results indicate that a high proportion of women in sites in 7 different countries were prescribed antibiotics, mostly for prophylaxis, during the intrapartum and postpartum periods. While there was large variation in their use among geographical areas, the Asian sites had the highest rates of use, with nearly all women, especially in India, receiving antibiotics following delivery.
The observation regarding the slightly lower but consistent decrease in non-study antibiotic use in women treated with azithromycin provides some evidence that the use of this antibiotic has an effect lasting into the period after facility discharge. We expect, but cannot prove, that the decrease in use of non-study antibiotics in the azithromycin group may have been related to decreased infections in the azithromycin group, results consistent with those from the overall APLUS study.
Conclusions
The high level of non-study antibiotic use, especially in the Asian sites, warrants concern. Given the high use of antibiotics, studies should consider whether more restrictive use of these antibiotics combined with azithromycin would be effective to align with WHO recommended AMS programs to reduce antimicrobial resistance.(23-24, 37-41) Further research is needed on implementation and effectiveness of such programs during obstetric care in LMICs.
Supplementary Material
Figure S1. CONSORT Diagram
Figure S2. Maternal Non-study Antibiotic Usage During Labor/Prior to Delivery by Antibiotic Type and Site
Figure S3. Maternal Non-study Antibiotic Usage in Facility After Delivery by Antibiotic Type and Site
Figure S4. Maternal Non-study Antibiotic Usage After Facility Discharge Until Day 42 by Antibiotic Type and Site
Acknowledgements:
We thank the mothers and families who participated in the study. The authors acknowledge the A-PLUS research teams for their many contributions.
Funding statement:
The A-PLUS study was supported through grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) [RTI International (U01 HD040636), University of North Carolina at Chapel Hill (U10 HD076465), University of Alabama at Birmingham (U10 HD078437), University of Colorado (U10 HD076474), Thomas Jefferson University (U10 HD076457), Columbia University (U10 HD078438), Boston University (U10 HD078439), Indiana University (U10 HD076461)] and a grant from the Foundation for the National Institutes of Health [MCCL19APT] through the Maternal, Newborn & Child Health Discovery & Tools initiative of the Bill & Melinda Gates Foundation (BMGF) [INV-008973]. The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the NICHD; the National Institutes of Health; or the U.S. Department of Health and Human Services or the BMGF.
Footnotes
Declaration of interest: The authors declare no conflicts of interest.
Ethical statement: The study was approved by the institutional review committees and ethical review committees at the participating sites as follows: Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (2/28/20); University of North Carolina, Chapel Hill, North Carolina, United States (4/26/20); University Teaching Hospital, Lusaka, Zambia (10/4/19); University of Alabama at Birmingham, US (7/1/20); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (8/3/20); University of Colorado School of Medicine, Denver, CO, US (4/12/19); International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh (6/30/20); University of Virginia, Charlottesville, Virginia, United States (6/10/20); KLE Academy Higher Education and Research, J N Medical College Belagavi, Karnataka, India (6/18/20); Thomas Jefferson University, Philadelphia, PA, USA (2/27/20); Aga Khan University, Karachi, Pakistan (9/19/19); Columbia University, New York, NY (8/11/20); Lata Medical Research Foundation, Nagpur, India (1/7/19); Boston university, Boston, MA (7/30/20); Moi University, Eldoret, Kenya (4/17/20); Indiana School of Medicine, University of Indiana, Indianapolis (7/28/20); RTI International, Durham, NC, US (9/30/19)
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1. CONSORT Diagram
Figure S2. Maternal Non-study Antibiotic Usage During Labor/Prior to Delivery by Antibiotic Type and Site
Figure S3. Maternal Non-study Antibiotic Usage in Facility After Delivery by Antibiotic Type and Site
Figure S4. Maternal Non-study Antibiotic Usage After Facility Discharge Until Day 42 by Antibiotic Type and Site