Half of Preterm Babies in Middle-Income Countries Miss the Cerebral Palsy Drug
Magnesium sulfate is inexpensive, widely available, and supported by decades of clinical trial evidence. When given to mothers before a preterm delivery, it can significantly reduce the risk of cerebral palsy in the newborn. International guidelines have recommended it for years. Despite all of this, fewer than half of premature babies in middle-income countries receive it.
That is the central finding of a review published in the International Journal of Gynecology and Obstetrics, which examined over a decade of data on two protective treatments for premature infants: magnesium sulfate and antenatal corticosteroids, which mature fetal lungs before delivery.
Twelve years of data, an unchanged divide
The analysis combined data from 45,619 babies born at 24 to 32 weeks of gestation at 1,111 hospitals in an international clinical network, supplemented by information from the UK National Neonatal Research Database and a broader literature review covering births from 2012 to 2024.
In high-income countries, an average of roughly three-quarters of eligible preterm infants were exposed to magnesium sulfate. In middle-income countries, that figure fell to less than half. Antenatal corticosteroids were used more consistently across income settings, but gaps remained even for that treatment.
The variation exists not just between income categories but within high-income countries as well. Individual hospitals within the same national health system showed wide differences in administration rates.
The failure is not scientific
"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 corresponding author Hannah B. Edwards, of the University of Bristol. The evidence base for both treatments is mature and consistent.
What drives the variation likely includes supply chain reliability, staff training and protocol implementation, institutional culture around guideline adoption, and the pressures of managing preterm deliveries - often emergency situations with limited time for deliberate decision-making.
England's PReCePT program - designed specifically to increase magnesium sulfate use - combined audit, feedback, structured training, and institutional support to produce measurable improvements. Edwards and coauthors argue its methods could translate to other healthcare systems facing the same implementation gap.
What equity would require
"The bigger-picture goal should now be to ensure that no matter where a baby is born, their mother has access to the evidence-based treatments that offer the best start in life," Edwards said.
Achieving that goal requires more than disseminating guidelines. The reasons for low uptake in specific settings are not well characterized by the available data - the analysis identifies the magnitude and persistence of the gap but cannot fully explain its causes. Understanding those causes, through qualitative research and health system analyses, is a prerequisite for effective intervention.
The hospital network used - the Vermont Oxford Network - is not a representative sample of all preterm births globally. Member institutions may differ from average hospitals in ways that affect reported rates. For the babies affected, those methodological caveats matter less than the underlying reality: a preventable source of cerebral palsy remains inadequately addressed in settings where it is needed most.