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The "Edge of Viability"

Updated: Feb 2, 2021

By PPL Board member Patricia Lee June, MD

What is “Viability”? Technically the word means “possessing the ability to live.” Commonly, the word is used relating to fetuses (the medical term for babies from the end of organ formation about 8 weeks after fertilization until birth) and their estimated ability to survive long term if born prematurely. While this is a useful concept, is it a theologically accurate one? Most babies prior to term possess the ability to live if allowed to remain in the womb (uterus) undisturbed. They are viable in-utero even if they are not viable if removed from their mother at that age. (Of course, there are exceptions such as placental insufficiency, abruption, eclampsia, etc., where the baby’s survival - and sometimes also the mother’s - is highest if delivered forthwith.)

But using the common rather than the theological definition, what is the edge of viability? The answer depends on when and where the child is born. When I was in medical school in 1973, it was not uncommon for a baby born around 32 weeks gestation to live for only a few days past birth and the Supreme Court used a date of 28 weeks in Roe vs Wade. By the late 1970’s, we could continually measure the oxygen content of the baby’s blood and a baby born at 27 weeks had a fighting chance but it was rare for a baby born at 26 weeks to go home alive. In the late 1980’s Surfactant became widely available and a rare baby at 24 weeks would survive.

Today, in the best hospitals, the survival rate for babies born at 22 weeks in Iowa is 40%. Of those who survive the delivery room, 69% survive to go home. At 23 weeks in Iowa, 70% survive (including 84% of those who are healthy enough to arrive in the NICU). In Sweden, 55% of babies born at 22 weeks and 65% of those born at 23 weeks survive. There are a few reports of babies born at 21 weeks surviving to hospital discharge, but no statistics.

Why do some babies survive while others die? Ultimately, according to His will, God has foreordained whatsoever comes to pass (Westminster Shorter Catechism, Q.6). Does mankind have no role in this? As Mordecai asked Esther “And who knows but that you have come to your royal position for such a time as this?” God uses humankind to carry out His will.

Do babies live or die due to their sin? Due to their parents’ sin? Surely other than original sin, these small babies have committed no sin, yet parental sin cannot be always ruled out, for example, if a mother goes into early labor/the placenta separates from the uterine wall after she smokes cocaine/methamphetamines, or if she had a previous surgical abortion. But as Jesus told those asking the same question about the man born blind, God foreordains what happens for His glory.

For these smallest babies, what correlates best with survival?

1. Place of birth – specifically, the attitudes of those who make policies and care for these babies in the place where the baby is born. At 22 weeks, if the policy is to offer comfort care or to only resuscitate babies deemed to have the best chance, the survival rate is often 0%. God chooses to use human physicians who practice active resuscitation to effect survival.

2. Place and year of birth – In previous eras and many places in the world, we did not have either the knowledge or technology needed to support these babies. The amount of experience of the hospital where the baby is born also makes a difference. (At least 100 babies below 26 weeks/year increases survival rates).

3. Factors specific to the baby (female, size, singleton versus multiple birth, C-section vs vaginal birth, infection, did the mother receive steroids within the past week, etc.) are much less important than the attitude and experience of those caring for the baby.

It is interesting to compare survival rates in Sweden, Norway, and the Netherlands. In the Netherlands, where children can be “euthanized” – deliberately killed legally, resuscitation and survival rates lag 2 weeks behind Sweden.

What about disability? Jesus would not quench a dimly burning wick, and the clay does not ask the potter why He made him that way – God does not value those of lessor physical or mental ability less than those we consider “perfect” or “normal”. And despite the predictions of those who value “quality of life” above life itself, most surviving preemies have no or only mild disabilities, particularly in the places with the highest survival rates. The no-more-than-mild disability rate varies in Iowa from half at 22 weeks to three-fourths at 23 weeks.

What can be done to prevent extreme prematurity? There is much we do not know, and even if we recognize factors associated with it, we cannot change or treat many of them. There are some behavioral modifications that will help:

1. Maintain a healthy weight. Obesity is a risk for hypertension and diabetes, both of which can necessitate early delivery.

2. Avoid drugs including tobacco, cocaine, and methamphetamines.

3. Limit stress as much as possible. Finish school, get a job, get married, and have sex in that order and limit sex to your spouse. Non-marital sex is associated with sexually transmitted infections, single parenthood, much higher rates of abortion, less stable relationships that are more prone to break up, increased violence, and higher stress levels.

4. Avoid abortion. Surgical abortions double or triple the risk of very early premature births in their younger siblings, and medical abortions are often incomplete, requiring surgical completion.

What is the edge of viability? For some, it will end within minutes or hours – or decades – whether in-utero or already born. For those born very prematurely in the best circumstances it is around 22 weeks, with rare survivors at 21 weeks where every day in-utero makes a difference. The survival rates of those born and resuscitated at 22 weeks are as good as that of adults given CPR for heart attacks or with brain cancer, strokes, or severe brain trauma; and the rate of disability is about the same.

Our smallest brothers and sisters deserve the same effort for survival as our adults do.
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