A study published this week in the New England Journal of Medicine documented a small number of cases in which premature babies born at 22 weeks survived with few health problems after receiving aggressive and highly-specialized medical treatment. But of the thousands of premature births reported in in the study, the great majority of babies born at 22 weeks died or suffered serious, long-term health issues.
The authors of the study, one of the most comprehensive to date on the kinds of care given to extremely premature babies, say it raises new questions for parents and doctors about what interventions might be taken when a baby is born so early. However, other physicians maintain that the study just confirms what is already known in the medical community: that, while rare, it is possible for a baby born at 22 weeks to survive. But the matter of what is medically possible and in the best interest of patients -- both parent and baby -- remains as complicated and case-specific as ever.
Which connects back to another question being raised in relation to the study: if some doctors are reconsidering the age of viability in light of the tiny fraction of cases in which babies survive at 22 weeks, are there implications for legal abortion? Abortion rights opponents have already pointed to the study as a possible instrument to challenge the concept of viability in Roe v. Wade.
The doctors I spoke with said this is the wrong question to ask. “This has nothing to do with abortion,” Dr. Stephen Chasen, the director of high-risk obstetrics at New York-Presbyterian Hospital Weill Cornell Medical Center whose practice focuses on prenatal diagnosis of fetal abnormalities and consultation in managing complicated pregnancies, told me. “The bottom line is that viability has never been a set number, it has always been determined by doctors based on the pregnancy. This study doesn’t change that.”
Dr. Kathleen Morrell, a New York-based OB-GYN, agreed, telling me that the study’s findings are “not news” to physicians. “When I trained 10 years ago, we knew that the viability of a baby was dependent on a lot of factors,” she explained. “What this paper highlights is the need for regional care.”
The study found that all but four of the 24 hospitals examined provided medical treatment to babies born at 22 weeks, but, as Morrell pointed out, the availability of care varies depending on the hospital. Rural hospitals, for example, may not have the equipment or capacity to provide such intensive interventions.
But even if every hospital in the country were outfitted with top of the line NICUs, the question of when to intervene remains medically and ethically complicated. Which is why, although the study itself has nothing to do with abortion, it has everything to do with the medical and legal concepts that are essential to reproductive freedom: namely, leaving doctors to make decisions using their own medical judgment, and allowing parents to decide what’s best for their child and for themselves.
Like the decision to terminate a pregnancy, the choice to pursue aggressive intervention after a premature birth is both a medical and ethical choice, and a highly personal one at that. It requires trusting parents and doctors to do what’s best given the specifics of the case. “It’s women and doctors who should make these decisions” Chasen told me.
There are “so many other issues that affect the likelihood of survival,” according to Morrell. “It’s the gestational age and how it was dated, it’s whether or not the women was given a 48 hours of a steroid injection that helps with lung maturity, it’s whether or not she is at the highest level of NICU,” she explained. Doctors and parents weigh their choices based on what’s in front of them.
Dr. Edward Bell, a pediatrics professor at the University of Iowa and one of the lead authors of the study, told the New York Times that he considers 22 weeks to be a new standard of viability. “That’s what we think, but this is a pretty controversial area,” he said. But other doctors are reluctant to make such pronouncements, and wary of potential consequences.
Dr. Jeffrey M. Perlman, medical director of neonatal intensive care at New York-Presbyterian Hospital Weill Cornell Medical Center, told the Times that months in neonatal units can be “like riding an obstacle course or flying in a plane with bad turbulence, and each of these down spirals can have an impact on the brain.” At Cornell, he continued, “we go after the 24-weekers. If it’s 23, we will talk to the family and explain to them that for us it’s an unknown pathway. At 22 weeks, in my opinion, the outcomes are so dismal that I don’t recommend any interventions.”
Dr. Jonathan Muraskas, a neonatologist at Loyola University Medical Center, told the Associated Press seemed skeptical of an approach that would recommend aggressive intervention in all cases of babies born extremely prematurely. “We just seem to be resuscitating more and more tinier babies, and there are consequences,” he said. “How low do we go and what are the implications?”
And there are consequences for baby and parent. A study released in 2009 by Stanford University found that parents of infants in prolonged intensive care experienced post-traumatic stress disorder as a result.
The first trauma is the shock of the premature birth, researchers found. “The second trauma is seeing their own infant having traumatic medical procedures and life-threatening events, and also witnessing other infants going through similar experiences,” Dr. Richard J. Shaw, an associate professor of child psychiatry at Stanford and the Lucile Packard Children’s Hospital and an author of the study, told the Times after the report was first published.
“And third, they often are given serial bad news,” he continued. “The bad news keeps coming. It’s different from a car accident or an assault or rape, where you get a single trauma and it’s over and you have to deal with it. With a preemie, every time you see your baby the experience comes up again.”
The study has made waves, but consensus among many doctors is that it doesn't change the medical and ethical realities parents and doctors face in such situations. Those remain just as knotty and, often, painful. Because of this, Morrell warned against politicizing the study.
But it's a real possibility in a landscape where conservatives in Congress and state legislatures have doubled down on efforts to ban abortion at 20 weeks. Republicans like Trent Franks and Marco Rubio have used discredited science on “fetal pain” to restrict access to the procedure, and may very well try to use this study to challenge the legal definition of viability.
"The study isn't about abortion, but it could enter into the conversation," Chasen said. But when lawmakers wade into complicated medical decisions -- whether it's about the best course of action after a baby is born at 22 weeks or the decision to terminate a pregnancy -- women and doctors lose out. The best treatment for an extremely premature baby is a "case-by-case, highly individualized thing,” Morrell told me. “The study just highlights for me, as a physician, how this needs to stay out of the hands of legislators.”
“You can’t legislate this,” she continued. “A woman and her family need to be able to have all options available to them.”
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