Most infants stay in their mothers' wombs for around 38 to 41 weeks before they join our world of lights, sounds and smells. Some infants however, defy Nature and relinquish the optimal home that is the uterus before time. The strong ones will ultimately survive and live normal lives but those who are born much too prematurely, such as those born at 23 weeks of gestation, face a battle for survival. But is this battle doomed from the start?

A gestational age of 23 weeks is considered as the edge of viability. Births occurring anytime earlier are usually considered as miscarriages. In the UK, nine out of a hundred infants born at 23 weeks of gestation will survive although only one of them will live a fully able-bodied life. What this means is that 91 of every hundred infants born at 23 weeks of gestation in the UK will die in the neonatal intensive care unit, eight others will be plagued for the rest of their lives by handicaps or severe medical conditions while only one will be able to live a normal life. Only one percent.

This revealing statistic begs the question: should these infants at the edge of life be saved at all?

In the placenta, the amniotic fluid bathes the infant and protects and nourishes it. The brain, which grows by three-fold in the last three months of pregnancy, is able to do so in the best possible environment. When such an explosive and crucial development is carried out outside the optimal conditions provided by the mother-as in the neonatal intensive care unit-however, the development may be hampered. For instance, continuous sensory bombardment may disrupt the infant's normal sleep-wake cycle while the number of medications administered may directly affect the brain, all leading to the possibility of brain injuries [1].

Injuries that occur very early during brain development may have very severe consequences. BBC Two's documentary, 23 Week Babies: The Price of Life, portrays Heather, who was born at the very edge of viability and suffered a hemorrhage in the first few weeks of her life. Now 21 years of age, Heather is permanently quadriplegic, able to use her left arm only.

"Basically if my mother or the carers don't come, I'm stuck in bed all day," she said. "I just wished I could end my life. There is obviously nothing else for me in my life, so what is the point of carrying on?"

There has long been concern about long-term outcome for very preterm survivors. Typically, those born before 25 weeks of gestation are attributed with poor quality of survival and too expensive treatments.

In the past twenty years however, tremendous progress has been made in neonatal care. Survival rates have gone up. The largest increase in infant survival rates in Victoria, Australia, from 1991 to 1997 has occurred in infants born at 23 weeks of gestation [2]. However, although survival rates have improved, it does not change the fact that, still, only a small fraction of those survivors will ever live a normal life.

With this in mind, the dilemma then is whether a life that has an eminent chance of being plagued by severe handicaps, as in Heather's case, is worth saving at all.

It is painful and harsh even that this dilemma falls on the shoulders of the family. In many ways, this situation is reminiscent of the dilemma imposed on the families of terminal patients. Prolong their lives by some days or months or allow them to drift away from all the suffering and despair?

As Atul Gawande narrates in his poignant article, Letting Go, about terminal patients in The New Yorker:

The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. [...]We'll sacrifice the quality of your existence now-by performing surgery, putting you in intensive care-for the chance of gaining time later.

While medicine has definitely made a lot of progress in recent times, we must be very aware that it is mostly powerless with regard to very preterm infants. It may save lives but most of the time, it's at terrible costs.

Image credit: Top ceejayoz (from Wikimedia Commons); Bottom Official U.S. Navy Imagery (from flickr)

References:

[1] Wyatt, J. Mechanisms of brain injury in the newborn. Eye 21, 1261-1263 (2007).

[2] Doyle, L. Neonatal intensive care at borderline viability--is it worth it? Early human development 80, 103-113 (2004).