Rich Countries Use Preterm Cerebral Palsy Drug at Twice the Rate of Middle-Income Nations
Two inexpensive treatments can substantially reduce the risk of cerebral palsy and respiratory failure in premature babies. Both have been recommended in clinical guidelines worldwide for years. Yet which babies actually receive them depends heavily on where they are born - and the gap between the best and worst-performing countries has not closed over the past decade.
Those are the central findings of an international study led by researchers at the University of Bristol, published in the International Journal of Obstetrics and Gynaecology. The team analyzed data from 45,619 babies born between 24 and 32 weeks of gestation at 1,111 hospitals across ten countries: the UK, Ireland, Austria, Switzerland, Italy, the United States, UAE, Brazil, South Africa, and India.
Two treatments, very different adoption rates
Magnesium sulfate, given to mothers before a preterm birth, reduces the likelihood of cerebral palsy in the baby - a condition that can cause lifelong motor and cognitive disability. Antenatal corticosteroids mature the baby's lungs before delivery, improving survival odds for infants born at the threshold of viability.
The contrast in how widely these treatments are used is stark. Ireland and the UK reported magnesium sulfate administration rates above 80% for eligible mothers. South Africa recorded 33.6%, and the UAE 44.5%. Averaged across income groups, high-income countries reached 74.8% while middle-income countries averaged 49.4%.
Antenatal corticosteroids showed less variation - they were used more consistently across countries - but treatment gaps remained even for that intervention.
The team supplemented the hospital network data with a review of ten additional studies covering 288,631 preterm babies and a comparison against UK National Neonatal Research Database figures.
The evidence is not the problem
"Our study has highlighted the international disparities in how two key treatments to protect pre-term babies are implemented. These gaps aren't because of a lack of evidence," said Hannah Edwards, Senior Research Associate in Medical Statistics at the University of Bristol and NIHR ARC West. Both treatments have been supported by strong trial evidence for decades.
What the study cannot determine is why rates remain low in specific settings. Implementation barriers likely vary by country: supply chain issues, healthcare worker training and awareness, institutional protocols, or resource constraints that make consistent administration difficult during high-pressure preterm deliveries.
The PReCePT program, developed in England, offers one model of what structured implementation support can achieve. The initiative focused specifically on increasing magnesium sulfate use in English hospitals and produced substantial improvements. Edwards and colleagues argue its blueprint could accelerate adoption in other health systems.
No improvement over time
The data spans 2012 to 2024. Over that period, the income-related gap in magnesium sulfate use did not narrow. This suggests that awareness of the treatments is not sufficient by itself to drive implementation - structured programs with active support and monitoring appear necessary.
Karen Luyt, PReCePT national clinical lead and Professor of Neonatal Medicine at the University of Bristol, called for international collaboration. "The use of MgSO4 to prevent cerebral palsy in pre-term infants is not equitable around the world. Our PReCePT blueprint for successful implementation of this life changing medication will be useful for accelerating use into routine clinical practice across international healthcare systems."
The hospital network used - the Vermont Oxford Network - is not a random sample of global hospitals. Member institutions may differ systematically from average hospitals in their countries, which could affect the representativeness of the figures.