‘Preemie’ Survival Lags, Could Stir Abortion Debate
There has been little improvement over the last seven years in the survival of the smallest and most premature babies, according to a study published today that may stoke the debate over the ethics of second-trimester abortions.
The study found that about one in five infants born before 25 weeks’ gestation--or weighing less than about 26 ounces--survived between 1985 and 1988. That rate was no better than the survival rate of similar babies born between 1982 and 1985.
That rate was unchanged despite increasingly aggressive attempts to keep such newborns alive, the researchers found. But the average time until death rose from 73 hours to 880 hours among those infants transferred to neonatal intensive care.
“Thus, although survival has not appreciably altered, in some instances we further postponed death by the futile continuation of respiratory support,” the authors wrote in a paper published in the New England Journal of Medicine.
The findings, from Case Western Reserve University School of Medicine in Cleveland, add new data to the debate over fetal viability--the critical point at which an infant could survive outside the womb and at which the state may intervene to block an abortion.
But the findings also raise questions about the ethics and economics of going to great lengths to salvage tiny infants unlikely to live: Amid attempts to control health care expenditures, is it right to try against the odds to save those babies?
“This is a cutting edge issue,” said Dr. Ezra Davidson, chairman of the department of obstetrics and gynecology at Drew University in Los Angeles. "(It) really poses a lot of ethical and medical problems in making a correct and comfortable decision.”
The researchers, Maureen Hack and Avroy A. Fanaroff, compared the cases of 98 infants weighing less than 750 grams, or 26.4 ounces, delivered at McDonald Hospital for Women between mid-1982 and mid-1985, to 129 similar infants delivered between 1985 and 1988.
The infants in the first group had been born after an average of 24.2 weeks’ gestation. The average in the second group was 23.5 weeks. Babies of that weight and prematurity represent about 0.5% of all babies born in the United States, physicians said.
The survival rate in the early 1980s was 20%. In the latter period, it was 18%. The rates were basically unchanged despite the fact that the percentage of infants resuscitated rose from 38% to 47% and the rate of Cesarean sections rose from 12% to 19%.
(Physicians say Cesarean sections may be used in these cases in hopes of protecting fragile infants from the trauma of vaginal delivery. But the procedure pits the surgery risk to the mother against the benefit to an infant unlikely to survive.)
“Thus, despite a tendency to perform more Cesarean sections and active resuscitations, no improvement in the survival of babies with lengths of gestation below 25 weeks or birth weights under 750 grams was observed,” the researchers wrote.
They said the probability of survival was even worse in the case of infants born after less than 24 weeks’ gestation and weighing less than 600 grams.
The researchers also tracked the development of some of the babies up to 20 months after birth. They found that four out of 18 studied in the first group, and seven out of 14 in the second group had “moderate-to-severe neurodevelopmental impairment.”
The impairment ranged from blindness to paralysis and abnormal development of tissue.
Because of the small numbers involved, the researchers were cautious about drawing conclusions from that sample. But they described the “trend toward an increase” in handicap “of serious concern.”
Asked Wednesday about the findings, opponents of abortion emphasized the fact that one in five infants had lived. They also noted that one infant survived after just 22 weeks’ gestation--two weeks less than the 24-week minimum often cited for viability.
Supporters of the right to abortion emphasized the finding that survival among infants born at less than 25 weeks had not improved. They said that confirms their current position that viability generally occurs after no less than 24 weeks.
The issue is considered significant because the U.S. Supreme Court ruled in 1973 that the state’s right to regulate abortion--by intervening to protect life--begins at the point of viability. The court estimated that a fetus could survive after 24 weeks.
“Here, they had a 22-weeker,” Dr. John Willke, president of the National Right to Life Committee, said in a telephone interview Wednesday. “To all those distinguished scientists with their absolutism, well, say no more.”
“The one-in-five rate doesn’t change my thinking or feeling about late second-trimester abortions,” said Barbara Radford, executive director of the National Abortion Federation. “I do think it’s really interesting that the survival rate hasn’t changed in that decade.”
Others, however, said the study’s significance extends far beyond abortion.
Al Jonsen, a professor of ethics in medicine at the University of Washington School of Medicine, said the findings raise the question of whether the science of saving premature babies has perhaps reached “some sort of physiological lower limit.”
The barrier to survival may no longer be simply the traditional problem of insufficiently developed lungs, he said. It may now be what Jonsen called “a complex of physiological under-development” and “the illness of not being finished.”
Jonsen said the findings raise two related, but separate, ethical questions:
“Is it justifiable to continue research into salvaging babies at the lower end of the scale?” he wondered. “What about rescue efforts? Can we legitimately exclude the whole class of babies under a particular weight and gestational age from therapeutic rescue efforts?”
The study’s authors suggested their findings would be useful in guiding health care providers and administrators in making medical policy decisions, and also in counseling parents with “unrealistic expectations” about the ability of medicine to keep alive an immature infant outside of the womb.