MAGnesium sulphate for fetal neuroprotection to prevent Cerebral Palsy (MAG-CP)—implementation of a national guideline in Canada

Abstract

BackgroundEvidence supports magnesium sulphate (MgSO4) for women at risk of imminent birth at < 32–34 weeks to reduce the likelihood of cerebral palsy in the child. MAGnesium sulphate for fetal neuroprotection to prevent Cerebral Palsy (MAG-CP) was a multifaceted knowledge translation (KT) strategy for this practice.MethodsThe KT strategy included national clinical practice guidelines, a national online e-learning module and, at MAG-CP sites, educational rounds, focus group discussions and surveys of barriers and facilitators. Participating sites contributed data on pregnancies with threatened very preterm birth. In an interrupted time-series study design, MgSO4 use for fetal neuroprotection (NP) was tracked prior to (Aug 2005–May 2011) and during (Jun 2011–Sept 2015) the KT intervention. Effectiveness of the strategy was measured by optimal MgSO4 use (i.e. administration when and only when indicated) over time, evaluated by a segmented generalised estimating equations logistic regression (p < 0.05 significant). Secondary outcomes included maternal effects and, using the Canadian Neonatal Network (CNN) database, national trends in MgSO4 use for fetal NP and associated neonatal resuscitation. With an anticipated recruitment of 3752 mothers over 4 years at Canadian Perinatal Network sites, we anticipated > 95% power to detect an increase in optimal MgSO4 use for fetal NP from < 5 to 80% (2-sided, alpha 0.05) and at least 80% power to detect any increases observed in maternal side effects from RCTs.ResultsSeven thousand eight hundred eighty-eight women with imminent preterm birth were eligible for MgSO4 for fetal NP: 4745 pre-KT (18 centres) and 3143 during KT (11 centres). The KT intervention was associated with an 84% increase in the odds of optimal use (OR 1.00 to 1.84, p < 0.001), a reduction in the odds of underuse (OR 1.00 to 0.47, p < 0.001) and an increase in suboptimal use (too early or at ≥ 32 weeks; OR 1.18 to 2.18, p < 0.001) of MgSO4 for fetal NP. Maternal hypotension was uncommon (7/1512, 0.5%). Nationally, intensive neonatal resuscitation decreased (p = 0.024) despite rising MgSO4 use for fetal NP (p < 0.001).ConclusionMultifaceted KT was associated with significant increases in use of MgSO4 for fetal NP, with neither important maternal nor neonatal risks.Electronic supplementary materialThe online version of this article (10.1186/s13012-017-0702-9) contains supplementary material, which is available to authorized users.

Survey on use of antenatal magnesium sulphate for fetal neuroprotection prior to preterm birth in Australia and New Zealand – Ongoing barriers and enablers

“…We are aware of three other countrywide assessments of practice and the increasing use of magnesium sulphate for fetal neuroprotection in Australia and New Zealand compares favourably with implementation projects, audits and surveys in these countries …”

“…In Canada, 11 of the 23 tertiary perinatal maternity centres received a knowledge transition strategy ‘MAG‐CP’ from 2011 to 2015 that included educational rounds, focus groups, surveys of barriers and facilitators to the implementation of the antenatal magnesium sulphate therapy at MAG‐CP sites . There were national clinical practice guidelines and an online e‐learning module.…”

“…There were national clinical practice guidelines and an online e‐learning module. Before implementation of the knowledge transition strategy in 2011, magnesium sulphate was administered to just 2% of eligible women, as assessed by sampling of eligible cases, and post‐implementation of the knowledge translation strategy, MAG‐CP, this increased to 46.3% by September 2015 …”

“…In comparison with France, this highlights the need for tailored projects to assist with the implementation of new practices, as has occurred in Australia and New Zealand with the WISH Project, in the West of England with PReCePT, and Canada with MAG‐CP. Implementation strategies, such as the WISH project, PReCePT and MAG‐CP have been successful at increasing the uptake of new, evidence‐based, clinical practice recommendations …”

“…We are aware of three other countrywide assessments of practice [21][22][23] and the increasing use of magnesium sulphate for fetal neuroprotection in Australia and New Zealand compares favourably with implementation projects, audits and surveys in these countries. 21,23 In France, an online and telephone survey carried out in 2014-2015 involving all French tertiary maternity hospitals reported 60.3% of hospitals used magnesium sulphate for fetal neuroprotection. 22 The top three barriers to use in France were lack of experience (52% of respondents), absence of a written protocol (49%) and absence of a national guideline (46%).…”