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.
Highlights
Evidence 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
The strategy consisted of four parts: (1) initiating and leading a Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guideline on the topic that was published in May 2011 [26] and from 2011 to 2015, (2) an e-learning module; (3) a ‘Barriers and Facilitators Survey’ and (4) an audit and feedback cycle, including site visits, monitoring and other interactive activities between the central MAGCP team and individual sites
We examined the proportion of babies who received MgSO4 for fetal NP from January 2011 when ‘fetal NP’ was first listed as an indication for MgSO4 in the Canadian Neonatal Network (CNN) database; as such, data were available for a portion of the pre-MAG-cerebral palsy (CP) (January– May 2011, inclusive) and during MAG-CP (i.e. June 2011– September 2015, inclusive)
Summary
Evidence 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. Knowledge gaps and lack of guidelines remained important barriers to use [16, 17], with the potential to cause maternal side effects an additional anticipated barrier as it has been for implementation of MgSO4 for eclampsia prevention and treatment [18]. As maternity care hospitals vary widely in terms of practices and beliefs, MAG-CP (MAGnesium sulphate for fetal neuroprotection to prevent Cerebral Palsy) was created to facilitate uptake of use of MgSO4 for fetal NP in the setting of imminent birth at < 32 weeks
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