A programme to increase the use of magnesium sulfate to reduce the risk of cerebral palsy is effective say researchers. Giving magnesium sulfate to women at risk of premature birth can reduce the risk of a child having cerebral palsy by a third, and costs just £1 per dose.
However, the authors of the new observational study, published in Archives of Disease in Childhood - Fetal and Neonatal Edition, pointed out that in 2017 only around two-thirds (64%) of eligible women were being given magnesium sulfate in England, Scotland, and Wales, with "wide regional variations".
To address this, in 2014 the PReCePT (Preventing Cerebral Palsy in Pre Term labour) quality improvement toolkit was developed by both parents and staff with the aim of supporting all maternity units in England to improve maternity staff awareness and increase the use of magnesium sulfate in mothers at risk of giving birth at 30 weeks’ gestation or under. PReCePT provided practical tools and training to support hospital staff to give magnesium sulfate to eligible mothers.
The pilot study in 2015, which involved five maternity units, found an increase in uptake from 21% to 88% associated with the PReCePT approach. Subsequently, in 2018, NHS England funded the National PReCePT Programme, which scaled up the intervention for national roll-out and provided the PReCePT quality toolkit – which includes preterm labour proforma, staff training presentations, parent information leaflet, posters for the unit, and a learning log – to each maternity unit.
Improvement 'Over and Above' Expectation
For the first evaluation of a UK universally implemented national perinatal quality improvement programme to increase administration of an evidence-based drug, researchers, led by University of Bristol, set out to evaluate the effectiveness and cost-effectiveness of the National PReCePT Programme in increasing use of magnesium sulfate in preterm births.
Using data from the UK National Neonatal Research Database for the year before and the year after PReCePT was implemented in maternity units in England, the researchers performed a before-and-after study that involved 137 maternity units within NHS England. Participants were babies born at 30 weeks’ gestation or under admitted to neonatal units in England, and the main outcome measure was magnesium sulfate uptake before and after the implementation of the National PReCePT Programme. In addition, implementation and lifetime costs were estimated.
During the first year, post implementation of the programme uptake increased by an average of 6.3 percentage points (to 83.1%) across all maternity units in England, which the authors explained was "over and above" the increase that would be expected over time as the practice spread organically. The researchers also found that after adjusting for variations in when maternity units started the programme, the increase in use of magnesium sulfate was 9.5 percentage points. "By May 2020, on average 86.4% of eligible mothers were receiving magnesium sulfate," they said.
Professor John Macleod, NIHR ARC West Director, professor in clinical epidemiology and primary care, University of Bristol, and principal investigator of the evaluation, said: "Our in-depth analysis has been able to demonstrate that the PReCePT programme is both effective and cost-effective. The programme has increased uptake of magnesium sulfate, which we know is a cost-effective medicine to prevent cerebral palsy, much more quickly than we could have otherwise expected."
From a societal and lifetime perspective, the health gains and cost savings associated with the National PReCePT Programme generated a "net monetary benefit of £866 per preterm baby", with the probability of the programme being cost-effective being "greater than 95%" the authors highlighted.
The researchers also estimated that the programme's first year could be associated with a lifetime saving to society of £3 million – which accounts for the costs of the programme, administering the treatment, of cerebral palsy to society over a lifetime, and the associated health gains of avoiding cases. "This is across all the extra babies the programme helped get access to the treatment during the first year," they said.
The authors highlighted that in the five pilot sites the improved use of magnesium sulfate has been "sustained over the years" since PReCePT was implemented. As the programme costs were mostly in the first year of implementation, longer-term national analysis may show that PReCePT is "even more cost-effective over a longer period," they postulated.
Uptake of new evidence or guidelines is often "slow" due to practical barriers, lack of knowledge, and need for behaviour change, and can "take decades to become embedded" in perinatal clinical practice, expressed the authors, which in turn comes at a "high clinical and economic cost".
Karen Luyt, professor in neonatal medicine, University of Bristol, said: "The PReCePT national quality improvement programme demonstrates that a collaborative and coordinated perinatal implementation programme supporting every hospital in England can accelerate the uptake of new evidence-based treatments into routine practice, enabling equitable health benefits to babies and ultimately reductions in lifetime societal costs."
The authors said The PReCePT model "may serve as a blueprint for future interventions to improve perinatal care".
Professor Lucy Chappell, chief executive officer of the National Institute for Health and Care Research, said: "This important study shows the impact of taking a promising intervention that had been shown to work in a research setting and scaling it up across the country. Giving magnesium sulfate to prevent cerebral palsy in premature babies is a simple, inexpensive intervention that can make such a difference to families and the health service."
Prof Macleod added: "We are pleased to have played a part in helping get this cheap yet effective treatment to more babies."
This work was jointly funded by the National Institute for Health and Care Research Applied Research Collaboration West and the AHSN Network funded by NHS England. The Health Foundation funded the health economics evaluation. The authors declare that the study management group has no competing financial, professional or personal interests that might have influenced the study design or conduct.