Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Was this editorial politically motivated?
- Peter J Saunders (12 May 2008)
-
Re: Was this editorial politically motivated?
- Fiona Godlee (13 May 2008)
-
Gestational Confusion
- Anthony D G Roberts (4 June 2008)
-
Antecedant events to premature delivery hinder the premature infant
- Malcolm John Dickson (5 June 2008)
|
|
|||
|
Peter J Saunders, General Secretary Christian Medical Fellowship
Send response to journal:
|
Dear Sir, I learnt about this editorial and the article to which it refers when I was sent an embargoed copy on Thursday 8 May and asked to comment. There has been huge media coverage since especially in the Independent and Guardian. However I was somewhat surprised to see that it was not in this week's paper edition of the BMJ which arrived today. Why the rush to get it on the web and into the public domain? The editorial says that upper time limits are to be debated in the House of Commons this year. What it doesn't say is that they are to be debated and voted on in just ten days time on 20 May. So the rush to get this into the public domain was to influence that debate. This was the same motivation which led to the massive media coverage around EPICURE 2 just a few weeks ago despite the fact that that research has not yet appeared in any peer-reviewed journal. And it is interesting to see that Evan Harris MP, who is leading the parliamentary campaign to keep the upper abortion limit at 24 weeks is widely quoted in the newspapers and clearly was alerted very early that this was coming. Did he perhaps also have a role in pushing this up the BMJ's agenda? It would be most interesting to know, but I suspect that we never will find out. The headlines have come and gone and the political opbjectives have been achieved. What about the science itself? Is there really no evidence that the survival of babies younger than 24 weeks has improved? We are told that Field and colleagues’ data are in keeping with other geographically defined population studies - and of course they are. The Trent results show that no babies survived at 22 weeks and less than one in five at 23 weeks. But the key issue here is whether public policy should be based on these sort of population studies or on best-practice models. The Unversity College London results published earlier this year (1) showed no survivors at 22 or 23 weeks in 1981-85 but 71% (5/7) and 47% (8/17) respectively in 1996-2000. These numbers may be too small to be statistically significant but they are highly suggestive of a trend in centres of excellence that rebuts the major premise of this editorial. Minneapolis figures in 2005 similarly showed 66% survival at 23 weeks (2). Furthermore the national statistics for 2005 recently highlighted by a Parliamentary question and published in the Telegraph confirm that babies do survive at 22 weeks in parts of the country other than Trent(3). Department of Health data show that 435 children were born after less than 24 weeks of pregnancy during 2005. Of those, 52 survived for at least a year. The data, for births in England and Wales, showed that eight of the 152 children born after 22 weeks' gestation lived for a year or more. At 23 weeks, 44 of 283 children survived. Of the 201,173 abortions in England and Wales in 2006, 1,262 were at 22 weeks or more. So it is clear that nationally in 2005 a significant number of babies were surviving below the current abortion limit. Even if viability is to be the sole criterion used for setting that 24 limit (and not any other of almost 20 reasons given by campaigners (4)) then surely that limit should come down on the basis that in one year 52 out of 435 babies survived below the limit and that in centres of excellence at 23 years like UCL and Minneapolis survival rates are around 50% or better. References 1. K Riley, S Roth, M Sellwood, JS Wyatt. Survival and neurodevelopmental morbidity at 1 year of age following extremely preterm delivery over a 20-year period: a single centre cohort study. Acta Paediatrica 2008; 97(2)159-165. http://www.blackwell-synergy.com/doi/abs/10.1111/j.1651-2227.2007.00637.x 2. Hoekstra RE et al. Survival and longterm neurodevelopmental outcome of extremely premature infants born at 23-26 weeks gestational age at a tertiary centre. Pediatrics 2004; 113: e1-e6. http://pediatrics.aappublications.org/cgi/content/full/113/1/e1 3. Many born within abortion limit survive. Daily Telegraph, 18 April 2008. http://www.telegraph.co.uk/news/uknews/1582935/Many-born-within- abortion-limit-survive.html 4. www.the20weekscampaign.org Competing interests: I would like to see the upper limit for abortion come down. |
|||
|
|
|||
|
Fiona Godlee, Editor, BMJ BMA House, London WC1H 9JR
Send response to journal:
|
Dear Peter Saunders, Many thanks for your query about the publication of the paper by Field et al and the accompanying editorial. The paper was not fast tracked and the accompanying editorial was commissioned in the usual way. Neither Evan Harris nor anyone else beyond ourselves and our peer reviewers had any hand in the decision making that led to publication. All research articles and their accompanying editorials are now published online ahead of print. We have done this for several years for the research papers and for the past year for accompanying editorials, and we will shortly be extending this continuous publication model to all BMJ content. Your question about what types of data should influence the public policy debate in this area is welcome and I look forward to hearing other views on this. Competing interests: None declared |
|||
|
|
|||
|
Anthony D G Roberts, Consultant Obstetrician and Gynaecologist Queens Hospital, Burton upon Trent, DE13 0RB
Send response to journal:
|
Professor Modi's editorial (BMJ 31 May 2008) adds value to the debate at the limits of viability and survival. She cites new data updating survival figures to 2005. The term gestation and gestational age are used in the paper and by common usage refer to the length of time from the last menstrual period to delivery. The true definition of gestation from the OED is "condition of being carried in the womb during the period between conception and birth" and this will, by deduction be two weeks less. In ordinary circumstances this will have no importance in the debate however the lay press can latch on to babies that survive at 22 weeks from IVF to delivery and hail these as survivors at 22 weeks gestation. They would be technically correct using the English definition, though the "medical" definition of such a pregnancy would be 24 weeks (22 weeks from IVF+2 weeks added amenorrhoea). Common usage is therefore fine provided absolutely all are using it. There are dangers when there is deviation between medical and English definitions. Competing interests: I have sat on an RCOG committee on beginning of life issues |
|||
|
|
|||
|
Malcolm John Dickson, Consultant Obstetrician Rochdale Infirmary, Lancashire, OL12 0NB
Send response to journal:
|
Professor Modi brings us the contemporary views as to survival following extreme premature birth. These views come from the best available research. Society is currently interested in at what gestational age an extremely premature infant has a reasonable chance of survival. Society is using this gestational age as the point beyond which abortion should not be allowed. Babies born at the extreme limits of viability are hindered not only by their immaturity – they are also affected by the antecedant events that promoted their delivery. Infection, prolonged membrane rupture, severe pre -eclampsia, abruptions and the like not only cause the premature delivery, they have adverse effects on the infant. Therefore society should not look to the gestational age of babies that have been exposed to and damaged by adverse ante-natal features to determine the gestational age of viability. It could be that a well grown baby, exposed to no adverse forces, electively delivered at 23 weeks could survive. Until we know this, we should not using the gestation at which these babies exposed to adverse features survive as the point at which an undamaged baby might reasonably survive. Nor should we be using the gestational age at which these damaged babies survive from as the point at which we allow abortion up to. Competing interests: None declared |
|||