Twenty-two weeks into my pregnancy, my husband and I sat in one of the exam rooms at Mass General Hospital in Boston, talking with my ob about the possibility of a delivery in the next few weeks.
An ultrasound had showed that my baby was too small for the stage of my pregnancy and that levels of amniotic fluid were low, likely because of a deteriorating placenta that would soon fail. But according to the “preemie calculator” on the National Institutes of Health website, which I had been checking for several days, most babies as small as mine, born before 26 weeks, either die in neonatal intensive care, or survive with a moderate to severe impairment as a result of their prematurity. Reading Internet message boards, I had come across an alternative, one that seemed to be publicly discussed only in the safety of those anonymous forums: to do nothing and let the fetus miscarry.
I did not know if this would be ethical, even legal, but I told my doctor that I thought our priority was the baby’s quality of life. He got it, nodded, and asked me to name a target birth weight and gestational age after which I would choose to deliver rather than lose the pregnancy.
As my husband and I went home to come up with those numbers, I puzzled over the ethics of the situation. It seemed clear that our target age for delivery would be beyond 24 weeks, the point of viability after which a baby has a better chance than not of surviving outside the womb. Following the idea in Roe v. Wade that the states may pass antiabortion legislation to protect viable fetuses, I wondered if it would be right for me to let my pregnancy miscarry after the stage at which it would be illegal to terminate it, 24 weeks in Massachusetts. And yet, as my ob’s obvious past experience counseling parents in our situation suggested, my husband and I were far from alone in being asked to choose between a likely stillbirth—the name commonly used for a miscarriage after 20 weeks—and the risks of a very early delivery.
The proportion of pregnant women classified as “high-risk” in the U.S. today is rising, with government data showing that risk factors like diabetes and hypertension in pregnancy are becoming more prevalent and reports documenting advancing maternal age and growing numbers of multiple gestations as a result of fertility treatments. Many American women deliver before 37 weeks (defined by a group of obstetricians in Europe in 1970 as “term” for a human pregnancy, though the most common length is 40 weeks) without having any choice in the matter; they find themselves in preterm labor, or they develop life-threatening complications such as HELLP syndrome, for which delivery is the only cure. But other women are faced with a choice about whether to bring their babies into the world early. For example, of the tens of thousands of American women who carry twins every year, one in four pregnancies is diagnosed with the same problem of intrauterine growth restriction or IUGR, as my baby was, and so are at an increased risk of stillbirth.
This rising tide of high-risk moms comes as improvements in neo-natal technology have made it possible for babies to survive outside the womb at 22 or even—it has been reported—21 weeks. That means delivery is on the table as a potential option for a fetus at risk many weeks earlier than would have been the case a generation ago. Yet at the same time, there is a growing awareness of the long-term consequences of prematurity for babies.
Ahmet Baschat, a maternal-fetal medicine expert at the University of Maryland Medical Center who has researched outcomes in IUGR pregnancies, published a paper in 2007 in which he found that the proportion of IUGR babies who survived without experiencing serious complications of prematurity in the NICU reaches only 50 percent at 28 weeks, and is just under 90 percent at 32. “Nonintervention is always an option,” he says.
In some parts of the country, however, that option is rarely taken. Michelle Owens is a maternal-fetal medicine specialist at the Wiser Hospital for Women and Infants in Jackson, Miss. Most of her patients deliver before 34 weeks, for several reasons. First, Owens’ hospital has the state’s only Level 4 NICU, so women who are at risk of very early delivery tend to be referred there. Second, Mississippi has a high proportion of poor and uninsured women with chronic health problems like diabetes and hypertension that are not well controlled in their pregnancies and a large population of African-Americans who are prone to preterm birth. (The state’s preterm birth rate is 18 percent, compared with just under 12 percent for the nation as a whole.) Third, the hospital sees a higher proportion of religious women who are less likely to terminate a fetus with genetic abnormalities, some of whom are also at increased risk of delivering early. Owens says her hospital offers delivery for fetal distress after 23 weeks and that among her patients, choosing to take a high risk of stillbirth is “highly uncommon,” even for a baby estimated to have less than a 10 percent chance of survival on the outside. “Most of our moms want to give a 450 gram baby that is at the limit of what our NICU can do a chance,” she says. “They don’t want an in-utero demise.”