This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Magnesium sulphate is a medicine recommended for pregnant women who go into labour early. It reduces their baby’s risk of developing cerebral palsy (a lifelong condition affecting movement and co-ordination). The medicine has been included in guidelines since 2015, but by 2017 only 2 in 3 eligible women were receiving it. New research showed how a national quality improvement programme accelerated maternity units’ use of the treatment. The programme could serve as a blueprint for future efforts to get clinical guidelines into practice in other areas of care.
The quality improvement programme was called PReCePT (Preventing Cerebral Palsy in Pre Term labour). It involved training staff on the benefits of magnesium sulphate, and having a local midwife dedicated to encouraging and monitoring use of the medicine at their maternity unit. The programme was supported by Academic Health Science Networks (a regional and national organisation that encourages improvement and innovation in healthcare).
The programme was both effective and cost-effective. Before it was introduced, about 7 in 10 eligible women in England received magnesium sulphate. This increased to more than 8 in 10 in the year after the programme was put in place. Magnesium sulphate is cheap (£1 per dose) and is estimated to save £1 million over a lifetime if cerebral palsy is avoided.
For more information on cerebral palsy, visit the NHS website.
UPDATE (23/11/2023): In a further randomised controlled trial, a sample of maternity units in the National PReCePT Programme was compared with units receiving additional support on top of standard resources. Magnesium sulfate use was similar in both arms of the trial, but the intervention was more cost-effective within the PReCePT Programme. The researchers say this adds to the evidence that the PReCePT programme’s approach could be a template for quality improvement in other areas of healthcare.
The issue: how to put clinical guidelines into practice
Magnesium sulphate is recommended by the National Institute for Health and Care Excellence (NICE) for pregnant women in preterm labour. It protects the baby’s developing brain, reducing their risk of cerebral palsy. The NICE guidelines were introduced in 2015, but by 2017 only 2 in 3 eligible women (in labour with a preterm baby) received the treatment. Its use varied across the country.
Some people with cerebral palsy have only minor problems; others are severely disabled. Symptoms can include jerky or uncontrolled movements, problems speaking or learning disabilities. People may need support throughout their lives to carry out daily tasks.
Quality improvement programmes in the NHS aim to improve the performance of the health service. PReCePT aimed specifically to increase the uptake of magnesium sulphate among mothers who go into labour less than 30 weeks into their pregnancy.
The PReCePT toolkit includes a range of resources: staff training presentations, a parent information leaflet, awareness-raising posters for maternity units, and a document to record whether women have received magnesium sulphate (since they sometimes move between wards and hospitals). Maternity units were funded so that each maternity unit had a ‘PReCePT champion’ midwife responsible for encouraging use of magnesium sulphate locally. Champions had protected time to, for instance, deliver training in their hospital. Each maternity unit across England received coaching from a regional clinical lead (such as an obstetrician) supported by Academic Health Science Networks.
The PReCePT programme was rolled out in England with the aim of increasing magnesium sulphate use to 85% by 2020. This study assessed the effectiveness and value for money offered by the programme.
What’s new?
The evaluation included 137 out of 155 maternity units in England. Researchers measured how many women received the medication, both before the programme was implemented and 12 months afterwards.
They found that:
- before the programme was implemented, on average 7 in 10 (71%) women in England received magnesium sulphate
- in the 12 months after the programme was implemented, this increased to more than 8 in 10 women (83%).
The study estimated that at least half of this improvement was a direct result of the PReCePT programme.
The programme was highly cost-effective. On average, each additional baby who received magnesium sulphate generated a saving of £866 over their lifetime, due to the prevention of cerebral palsy. That is a total of £3 million in the first year of the programme. Ongoing cost savings will continue to grow if the effect is sustained.
Why is this important?
This quality improvement programme was effective and cost-effective. It shows that this national programme, delivered with support from Academic Health Science Networks, accelerated improvements in maternity care. This was the first evaluation of a UK perinatal quality improvement programme aiming to increase the uptake of a drug.
It can take years for guidelines to be put into practice, because of practical barriers and a lack of staff knowledge, for example. This comes at a high clinical and economic cost. Quality improvement programmes could speed up the implementation process.
Use of magnesium sulphate increased by more than 10% in 2 years. By contrast, with no similar quality improvement programme, it took 17 years for the use of antenatal steroids (to help premature babies’ lungs develop) to show a similar increase. The quality improvement programme helped put guidelines into practice and improved care for mothers and babies.
Before the programme, eligible women in some hospitals and some parts of the country were less likely to receive magnesium sulphate. After the programme, use of the medicine was more equal across England.
The researchers say that the increased uptake of magnesium sulphate is likely to be sustained. Use of magnesium sulphate has remained high in the maternity units that took part in the original pilot study 4 years ago. This sustained behaviour change could also mean the programme becomes more cost-effective over time. Implementation of the programme cost on average £6044 per maternity unit. After this initial investment, little or no further money should be needed to sustain the increased uptake.
Other factors will have contributed to the increase in use of magnesium sulphate. But this evaluation provides strong evidence that the PReCePT national programme increased its use.
What’s next?
The researchers believe this type of quality improvement programme could be used in other areas of care, not just in pregnancy. The model – including training, local champions, and support from Academic Health Science Networks – could be an effective way to drive improvement across the NHS. The team is working with NICE to develop an example toolkit for other quality improvement programmes to help put guidelines into practice.
The researchers are continuing to monitor the use of magnesium sulphate across England. They are planning another evaluation to compare how it is used in Wales and Scotland.
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This Alert is based on: Edwards HB, and others. National PReCePT Programme: a before-and-after evaluation of the implementation of a national quality improvement programme to increase the uptake of magnesium sulfate in preterm deliveries. Archives of Disease in Childhood Fetal and Neonatal Edition 2023; 0:F1–F6.
A film about the study hosted on YouTube.
A plain language summary of the study on the Applied Research Collaboration's website.
A blog about the impact of the study on the Applied Research Collaboration's website.
Funding: This study was funded by the NIHR Applied Research Collaboration West.
Conflicts of Interest: View the original paper for the author’s conflicts of interest.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
