Barriers and enablers to implementing antenatal magnesium sulphate for fetal neuroprotection guidelines: a study using the theoretical domains framework.

Emily Bain,Pat Ashwood,Sally Reid,Tanya Bubner,Emer Van Ryswyk,Lucy Simmonds,Philippa Middleton,Caroline A Crowther

doi:10.1186/s12884-015-0618-9

Abstract

BackgroundStrong evidence supports administration of magnesium sulphate prior to birth at less than 30 weeks’ gestation to prevent very preterm babies dying or developing cerebral palsy. This study was undertaken as part of The WISH (Working to Improve Survival and Health for babies born very preterm) Project, to assess health professionals’ self-reported use of antenatal magnesium sulphate, and barriers and enablers to implementation of 2010 Australian and New Zealand clinical practice guidelines.MethodsSemi-structured, one-to-one interviews were conducted with obstetric and neonatal consultants and trainees, and midwives in 2011 (n = 24) and 2012–2013 (n = 21) at the Women’s and Children’s Hospital, South Australia. Transcribed interview data were coded using the Theoretical Domains Framework (describing 14 domains related to behaviour change) for analysis of barriers and enablers.ResultsIn 2012–13, health professionals more often reported ‘routinely’ or ‘sometimes’ administering or advising their colleagues to administer magnesium sulphate for fetal neuroprotection (86 % in 2012–13 vs. 46 % in 2011). ‘Knowledge and skills’, ‘memory, attention and decision processes’, ‘environmental context and resources’, ‘beliefs about consequences’ and ‘social influences’ were key domains identified in the barrier and enabler analysis. Perceived barriers were the complex administration processes, time pressures, and the unpredictability of preterm birth. Enablers included education for staff and women at risk of very preterm birth, reminders and ‘prompts’, simplified processes for administration, and influential colleagues.ConclusionsThis study has provided valuable data on barriers and enablers to implementing magnesium sulphate for fetal neuroprotection, with implications for designing and modifying future behaviour change strategies, to ensure optimal uptake of this neuroprotective therapy for very preterm infants.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0618-9) contains supplementary material, which is available to authorized users.

Highlights

Strong evidence supports administration of magnesium sulphate prior to birth at less than 30 weeks’ gestation to prevent very preterm babies dying or developing cerebral palsy
A case control study described an association between maternal receipt of magnesium sulphate and a reduction in cerebral palsy for very low birthweight infants [5]
Subsequent to this and other observational studies, five randomised controlled trials were conducted assessing antenatally administered magnesium sulphate for preventing cerebral palsy [6,7,8,9,10]. These five trials were included in a Cochrane systematic review, which confirmed benefit, showing that 63 mothers need to be given magnesium sulphate prior to very preterm birth to prevent one case of cerebral palsy [11]

Summary

Introduction

Strong evidence supports administration of magnesium sulphate prior to birth at less than 30 weeks’ gestation to prevent very preterm babies dying or developing cerebral palsy. Based on knowledge of interventions likely to increase uptake of evidence into obstetric practice, an implementation project WISH (Working to Improve Survival and Health for babies born very preterm) was planned, and funded by the Cerebral Palsy Alliance Research Foundation [15]. This Project is ongoing and comprises a package of active implementation strategies to guide the introduction and local adaptation of guideline recommendations, and to monitor and improve uptake and health outcomes [15]

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Discussion

Conclusion