Andrew Fergusson reports on a BBC documentary addressing babies born prematurely at 23 weeks

Andrew Fergusson

In mid-March a BBC TV documentary asked whether there is any point in the NHS caring for babies born at 23 weeks' gestation - much earlier than the 40 weeks of a full term normal pregnancy. The take-home message, backed up by comments from some medical sources, was 'no'. Many will die; many of the survivors will be left with significant lifelong medical problems; and the costs - both financially to the NHS and emotionally to parents and staff - are high.

Reviewing this programme, and expressing solely his own opinions, Emeritus Professor of Neonatal Paediatrics at University College London Hospital, John Wyatt said, 'Brilliantly filmed and produced, the programme powerfully illustrated the conflicting emotions of parents confronted with a baby struggling for life at 23 weeks. Four words came to mind: pain, hope, love, despair. As a mother cuddled the tiny form of her bruised and dying baby she whispered, "Little princess - you are so beautiful."'

He continued, 'So our first response should be one of common humanity - to identify with the pain of the parents, and the extremely difficult dilemmas which delivery at the limits of viability raises. But although the programme showed the heart-breaking reality of neonatal death...the underlying theme was expressed in stark form. 'Is it worth trying to keep these babies alive?' The opinion of many of the professionals interviewed was clearly "No".'

Questions the programme ignored:

Beginning to disagree, he raised a number of technical and clinical factors, not mentioned in the programme:

• Inaccuracy in gestational age - dates can be wrong by 4-14 days with a significant difference in outcomes


• Other factors besides gestational age are crucially important - birth weight, gender, single or multiple pregnancy, whether steroids have been given


• Outcomes vary between different neonatal units depending on how experienced and how well equipped and staffed the units are


• Outcome figures depend on management policies and ethical attitudes to extremely premature babies - negativity tends to be self-fulfilling


• Most extremely preterm survivors rate their own quality of life highly - so what do negative attitudes say to such people?


• Care for disabled children and adults is frequently inadequate


• Can there be future improvement in the outlook for premature babies?


• Banning resuscitation at 23 weeks would have an infinitesimal effect on the resources of the NHS - although care is expensive, numbers are tiny


• Do these babies have human rights or should they be treated as fetuses?


• Should the parents be involved in the decisions? (he concludes that parents and doctors should collaborate)

John ended this comprehensive analysis, 'Each baby deserves the best possible care. Yet the decision as to whether to commence resuscitation or not is complex and painful. In some cases it is clearly right that doctors say "enough is enough". Just because a treatment is available does not mean that it should be used. But if there is a realistic chance that this particular baby can survive without overwhelming and catastrophic injury, then surely as a rich country we owe it to each child to give them a chance of life.

'These decisions are painful and difficult. The programme showed the depth of the pain and distress experienced by parents and by the staff caring for them. But there is no reason for doom and gloom about premature babies. We should celebrate the successes that have been achieved, value the lives of those who have survived against all the odds, whether disabled or not, and look forward to future advances in the care of these vulnerable citizens.'

As a neonatal paediatrician, and a committed Christian, you might think, 'he would say all that, wouldn't he?' Read John's evidence and arguments and decide for yourself. But beyond ethical debate and management policy in the care of 23-week babies itself, lie two further questions affecting the abortion debate. Perhaps the politics of that debate muddy these waters further?

Abortion up to 24 weeks?

The first is that the 1967 Abortion Act, amended in 1990, sets an upper limit of 24 weeks' gestation for the vast majority of abortions. 96% of the 200,000 abortions each year in Great Britain are performed on (allegedly) mental health grounds under Ground C: 'the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman'.

If babies are being aborted as late as 23 weeks, and there is a small number each year who are, then that raises a question we know troubles the pro-choice movement, as well as many health professionals. Why should one baby at 23 weeks live, when one, perhaps in an adjacent suite, is being aborted? One is 'wanted' and the other isn't, and that does not seem a satisfactory explanation to anyone.

The other link with the Abortion Act is that we now know for certain that having an abortion increases the risk of subsequent pre-term delivery. In other words, some of those ethically and clinically troublesome 23 week wanted babies may be coming into the world too early because mum has previously had one or more abortions.

So, are they too old to die young too?