Implementation of national guidelines on antenatal magnesium sulfate for neonatal neuroprotection in England, Scotland and Wales: Extended evaluation of the effectiveness and cost-effectiveness of the National PReCePT Programme

Abstract

BackgroundSince 2015, UK national guidelines have recommended antenatal magnesium sulfate (MgSO4) for mothers in preterm labour (<30 weeks’ gestation) to reduce the risk of cerebral palsy in the preterm baby. However, implementation of this guideline in clinical practice was slow, and MgSO4use varied between maternity units. In 2018, the PReCePT programme, an evidence-based Quality Improvement intervention to improve use of MgSO4, was rolled-out across England. Earlier evaluation found this programme to be effective and cost-effective over the first 12 months. We extended the original evaluation to determine the programme’s longer-term impact over four years, its impact in later preterm births, impact of the COVID-19 pandemic, and to compare MgSO4use in England, Scotland, and Wales.MethodsQuasi-experimental longitudinal study using data from the National Neonatal Research Database on babies born <30 weeks’ gestation and admitted to an NHS neonatal unit. Primary outcome was the proportion of eligible mothers receiving MgSO4, aggregated to the national level. Impact of PReCePT on MgSO4use was estimated using multivariable linear regression. The net monetary benefit (NMB) of the programme was estimated.ResultsMgSO4administration rose from 65.8% in 2017 to 85.5% in 2022 in England. PReCePT was associated with 5.8 percentage points improvement in uptake (95%CI 2.69 to 8.86, p<0.001). Improvement was greater when including older preterm births (<34 weeks’ gestation, 8.67 percentage points, 95%CI 6.38 to 10.96, p<0.001). Most gains occurred in the first two years following implementation. PReCePT had a NMB of £597,000 with 89% probability of being cost-effective. Following implementation, English uptake appeared to accelerate compared to Scotland and Wales. There was some decline in use coinciding with the onset of the pandemic.ConclusionsThe PReCePT Quality Improvement programme cost-effectively improved use of antenatal MgSO4, with benefits to the babies who have been protected from cerebral palsy.What is already known on this topicAntenatal magnesium sulphate (MgSO4) reduces the risk of cerebral palsy in babies born preterm.The National PReCePT Quality Improvement Programme (NPP) effectively and cost-effectively improved use of MgSO4in England in the first 12 months of implementation, but sustaining quality improvements over time is often challenging.What this study addsUsing a quasi-experimental design and routinely collected, longitudinal, patient-level data, this study found that the NPP had sustained effectiveness and cost-effectiveness over four years following implementation.Improvement may have been accelerated in England, compared to Scotland and Wales, where the NPP was not formally implemented.How this study might affect research, practice or policyThis study demonstrates that dedicated national programmes can cost-effectively achieve improvements in perinatal care. The PReCePT model could be used as an implementation blueprint for other quality improvement initiatives in perinatal care.