“For me as a clinical midwife, I've learnt so much stuff. It was a real steep learning curve. It was a real collaboration, certainly I couldn't have done it on my own.”
Project midwife
Overview

Every year around 4,000 women in the UK give birth very early because of complications with their pregnancy. Being born too early is the leading cause of cerebral palsy, which has a lifelong impact on children and families.

Magnesium sulphate (MgSO4) given during preterm labour reduces the relative risk of cerebral palsy in very preterm infants by 30% and costs from just £1 a dose. For every 37 women given MgSO4, one case of cerebral palsy is avoided.

The Prevention of Cerebral Palsy in PreTerm Labour (PReCePT) programme was developed by the West of England AHSN in collaboration with University Hospitals Bristol and Weston NHS Foundation Trust and involved both patients and staff.

Selected as an AHSN Network national programme from April 2018 to March 2020, AHSNs worked with maternity hospitals in England to make MgSO4 available to mothers who go into labour at less than 30 weeks. It was the first ever perinatal quality improvement (QI) programme delivered at scale across the whole country, bringing together midwives, obstetricians and neonatologists.

This work mobilised the 15 AHSNs and the aligned drivers of the Maternal and Neonatal Health Safety Collaborative (MNHSC) and the national Patient Safety Collaboratives (PSCs) to support the aim of achieving 85% uptake of administration of MgSO4 to preterm babies in all maternity units in England.

At the end of the AHSN Network national programme all 152 maternity units in England had adopted PReCePT; the programme aim of 85% uptake had been achieved and variation in administration significantly reduced.

Over the course of the programme an estimated 48 cases of cerebral palsy were avoided as a result of PReCePT, saving an estimated £38.4 million in lifetime health and social care costs (figures from 2018-2021).

Challenge/ problem identified

Around one in ten babies of very low birth weight develop a form of cerebral palsy. It is estimated that the lifetime cost per patient with cerebral palsy, including health care, productivity and social costs, is in the region of €830,000 (1).

In 2015 NICE (NG25) recommended administration of magnesium sulphate (MgSO4) in very preterm births as a core part of maternity care to substantially reduce the risk of cerebral palsy by 30%, based on accumulating evidence in support of its brain protective potential (2).

For every 37 mothers below 30 weeks gestation who receive magnesium sulphate, one case of cerebral palsy is prevented.

However, the uptake of MgSO4 in the UK remained relatively low, compared with the rest of the developed world, and this problem applied nationwide (with the exception of a few well-performing maternity units). The National Neonatal Audit Programmes report demonstrated an uptake of 44% for eligible babies in England in 2016, and 60% in 2017 (3).

  1. Kruse M, Michelsen SI, Flachs EM, Bronnum-Hansen H, Madsen M, Uldall P. Lifetime costs of cerebral palsy. Developmental Medicine and Child Neurology. 2009;51(8):622-8.
  2. 2015 NICE Guideline 25: Preterm labour and birth. National Institute for Health and Care Excellence (Available from: https://www.nice.org.uk/Guidance/NG25)
  3. National Neonatal Audit programme (NNAP) 2017 and 2018 [Available from: http://www.rcpch.ac.uk/improving-child-health/quality-improvement-and-clinicalaudit/national-neonatal-audit-programme-nn-3)
Actions taken

The West of England AHSN developed PReCePT in collaboration with University Hospitals Bristol and Weston NHS Foundation Trust to help reduce cerebral palsy in preterm babies by optimising administration of magnesium sulphate (MgSO4) to women in preterm labour (less than 30 weeks).

Co-designed with a wide range of stakeholders, including patients, clinicians and management, PReCePT provided a supported quality improvement (QI) toolkit and information materials as well as practical tools and training to raise awareness of evidence-based practice on use of MgSO4 compliance, supporting staff to consider MgSO4 in eligible pregnancies.

Between March 2014 and March 2015 with Dr Karen Luyt as the clinical lead, the West of England AHSN coordinated the introduction and supported the adoption of PReCePT in all five maternity units in the region, identifying lead midwives in each trust to champion the initiative.

Projection modelling indicates that the impact of this first phase of PReCePT was at least seven cases of cerebral palsy across the region were prevented, representing potential lifetime healthcare savings in the region of £5 million – and substantially more when including loss of productivity and social care costs over a lifetime.

The independent evaluation of this first phase of PReCePT by NIHR ARC West was published in the British Medical Journal Open Quality in 2017.

Following the successful rollout of PReCePT across the West of England, PReCePT was selected as one of the AHSN Network’s seven adoption and spread programmes during 2018-2020, funded by NHS England. The West of England AHSN led on this programme.

This work brought together the AHSNs and the aligned drivers of the Maternal and Neonatal Health Safety Collaborative (MNHSC) and the national Patient Safety Collaboratives (PSCs) to support the aim of achieving 85% uptake of administration of magnesium sulphate to preterm babies in all maternity units in England by March 2020.

The PReCePT programme took a network approach, delivering it through the 15 AHSNs using standardised QI resources such as toolkits, implementation guides, dashboards, clinical role descriptions, training presentations and promotional collateral. Midwife champions were funded to deliver PReCePT in each maternity unit and regional clinical leads were employed to support the delivery of the programme across each AHSN geographical area.

PReCePT also benefitted from £0.5 million in ‘Scaling Up’ funding from the Health Foundation to run a cluster randomized trial nested within the national programme. Known as the PReCePT Study, this aimed to assess whether an enhanced QI intervention improved the uptake of MgSO4 in preterm births over and above the national PReCePT programme.

40 maternity units in England were randomly selected to receive either enhanced QI support from the PReCePT Study team (13 units) or be observed while implementing the standard support model delivered via the national AHSN Network programme (27 units).

University Hospitals Bristol and Weston NHS Foundation Trust led the PReCePT Study, working in partnership with NIHR ARC West and the West of England AHSN. Read more about the PReCePT Study here.

Impacts / outcomes

PReCePT has led to improved compliance with NICE guidance (NG25), through its publicity campaign to increase awareness about the use of MgSO4 as a neuroprotector, developing care pathways and a range of tools to spread and embed this message.

By the end of the AHSN Network national programme in March 2020, all 152 maternity units in England had adopted PReCePT; the programme aim of 85% uptake had been achieved and variation in administration significantly reduced.

Over the course of the programme an estimated 48 cases of cerebral palsy were avoided as a result of PReCePT, saving an estimated £38.4 million in lifetime health and social care costs (figures from 2018-2021).

Midwives in lead or champion roles were able to develop their units, themselves and each other in QI skills and thinking, moving away from the wasteful model of individuals working within their own professional silos and workplaces to one of collective action and harmonisation of efforts.

An important outcome of the programme was increased accuracy in reporting and collection of MgSO4 administration data, data monitoring, and follow-up of missed cases.

The NIHR ARC West evaluation also identified a range of organisational and social factors that require consideration when developing large scale implementation programmes.

The PReCePT programme was formally endorsed by:

  • Bliss, the charity for babies born premature or sick
  • Tommy’s, which funds research into miscarriage, premature birth and stillbirth and provides information to parents-to-be
  • Tamba, the twins and multiple births association
  • The British Association of Perinatal Medicine
  • The Royal College of Midwives
  • The Royal College of Obstetricians and Gynaecologists.
Plans for the future

The administration of MgSO4 as a neuroprotector has been included in the NHS Long Term Plan, the national Patient Safety Strategy as well as Saving Babies Lives v2. It is a key component of the national Maternity and Neonatal Safety Improvement Programme’s Optimisation and Stabilisation of the Preterm Infant primary driver.

The West of England AHSN, on behalf of the AHSN Network, is exploring the opportunity to collaborate with NIHR ARC West, industry and voluntary sector partners on a research project that links patient level MgSO4 administration data with cerebral palsy diagnosis. Further information on whether this project progresses will be available in 2022.

Start and end dates
  • West of England: March 2014 – March 2015
  • AHSN Network adoption and spread programme: April 2018 – March 2020
  • Health Foundation PReCePT Study / ‘Scaling Up’ project: April 2018 – November 2020
Contacts

National programme contact

Ellie Wetz, Programme Manager, West of England AHSN
E: ellie.wetz@nhs.net

Media contact

Vanesther Hamer, Head of Communications, West of England AHSN
E: vanesther.hamer@nhs.net

 

PReCePT: Reducing cerebral palsy through improving uptake of magnesium sulphate in preterm deliveries