The tiniest babies: Shifting the boundary of life earlier
BIRMINGHAM, ALA. >> Michelle Butler was just over halfway through her pregnancy when her water broke and contractions wracked her body. She couldn't escape a terrifying truth: Her twins were coming much too soon.
Dr. Brian Sims entered the delivery room and gently explained that babies born so early likely won't live. He told Butler he could keep them comfortable as they died.
But she pleaded through tears: “Give my twins a chance to survive.”
And he did.
Until recently, trying to save babies born this early would have been futile. Butler was in the fifth month of her pregnancy, one day past 21 weeks gestation. That's seven weeks earlier than what doctors once considered “the lower limit of viability,” the earliest an infant could possibly survive outside the womb. But over the last half century, medical science has slowly shifted that boundary downward.
And that's made viability — a word many associate with the abortion debate — key to decisions about desperately wanted babies at the very edge of life.
Growing numbers of extremely premature infants are getting lifesaving treatment and surviving. A pivotal study in the Journal of the American Medical Association this year, which looked at nearly 11,000 such births in a neonatal research network that is part of the National Institutes of Health, found that 30% of babies born at 22 weeks, 56% born at 23 weeks and 71% born at 24 weeks lived at least until they were healthy enough to be sent home if doctors tried to save them.
Those gains happened gradually and quietly as the notion of viability got a lot more attention in the abortion arena. Viability is mentioned 36 times in the initial draft of the leaked majority opinion by the U.S. Supreme Court in a Mississippi case that would strike down Roe v. Wade. The decades-old abortion ruling says the Constitution protects a woman's right to an abortion before viability, a standard Mississippi argues is arbitrary.
But viability has nothing to do with the vast majority of abortions; more than 99% of abortions occur at or before 21 weeks, according to federal statistics. So although viability is central to abortion law, the crux of the argument around the procedure comes down to disagreement about whether and in which cases someone should have the choice to terminate a pregnancy.
Meanwhile, viability is a growing real concern for those who care for premature babies as science keeps moving the line lower and lower.
And in this realm, too, it's ethically fraught.
Beyond the risk of death, babies at “borderline viability” are highly susceptible to disabilities such as cerebral palsy, cognitive impairments, blindness and severe lung problems. Often, parents and doctors face a heartbreaking question they must answer together: How do they decide what to do?
“There's a lot of things we can do, a lot of interventions,” said Dr. Barbara Warner, a newborn medicine expert at Washington University medical school in St. Louis. “Should we do them?”
In the case of Butler's twins, the answer was yes. Curtis and C'Asya Means came into the world on July 5, 2020, at the University of Alabama hospital in Birmingham, each weighing less than a pound and small enough to fit in an adult's hand.
Their divergent paths reflected both sides of extreme prematurity.
C'Asya lived just one day. Butler keeps her ashes in a tiny pink-and-silver urn.
Curtis is the earliest surviving “micropreemie” in the world and is now teething, trying solid foods and tooling around the house in his walker.