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With interest we read the new framework from the British Association of Perinatal Medicine (BAPM) (1) and the news item in BMJ by Elisabeth Mahase (2). We congratulate the working group with a big step forward in perinatal management for extreme premature born neonates. We agree with the risk assessment what is proposed in the framework. However we would propose and encourage to make it an even more individual assessment. As Dominic Wilkinson says that ‘these complex decisions can’t be reduced to simple rules.’ Guidelines tend to make an oversimplification of a complex situation. In all other medical difficult situations we personalize medicine more and more, why not in perinatal care for the parents of extreme premature babies. A guideline also tends to leave less opportunity for patients choosing themselves.
Important to note, although gestational age (GA) is often seen as a highly accurate fact, it is not. Although other risk factors are incorporated in the new framework, we should value the fact that GA alone does not accurately predict outcome.
Not only fetal characteristics matter, personal views and circumstances of the parents can make an essential difference. A patient of 43 years, pregnant after many years of IVF will encounter risks of survival and surviving with severe impairment totally different than a patient of 21 years, accidentally pregnant during her study.
At last, we should discuss with the parents ‘what is good outcome? ’Most (future) parents, like most caregivers find severe disability the worst outcome, however some will not.
Concluding we believe it is important to boost the discussion on this difficult but very important topic by proposing a personalized multidisciplinary approach rather than using the current guidelines.
1. British Association of Perinatal Medicine. Perinatal management of extreme preterm birth before 27 weeks of gestation: a framework for practice. Oct 2019. https://www.bapm.org/resources/category/BAPM%20Frameworks%20for%20Practice.
2. Mahese E. Consider active management for premature babies born at 22 weeks, says new guidance. BMJ. 2019 22;367:l6151.
It is indeed very good news that active management should be considered for babies born at 22 weeks.
I find it though very alarming that babies in utero at that gestation can be terminated with their bodies disposed as human waste whereas a born baby at that gestation will be provided with care.
Why is a baby in utero stripped of its humanity just because it is in utero? That baby was still a baby in utero. Delivery has not made it into a person. That baby was already a person. Travelling along the birth canal is not what creates a person.
It seems that the baby in utero is dehumanised just as slaves were dehumanised by those who enslaved them, Jews dehumanised by the Nazis. These are extremely worrying antecedents. The unborn have no voices, they are the weakest and most vulnerable members of our society.
In the light of the findings of the article it also extremely disturbing that the Northern Ireland abortion limit has been set at a record high of 28 weeks contrary to the rest of Europe.
Re: Consider active management for premature babies born at 22 weeks, says new guidance
Dear Editor,
With interest we read the new framework from the British Association of Perinatal Medicine (BAPM) (1) and the news item in BMJ by Elisabeth Mahase (2). We congratulate the working group with a big step forward in perinatal management for extreme premature born neonates. We agree with the risk assessment what is proposed in the framework. However we would propose and encourage to make it an even more individual assessment. As Dominic Wilkinson says that ‘these complex decisions can’t be reduced to simple rules.’ Guidelines tend to make an oversimplification of a complex situation. In all other medical difficult situations we personalize medicine more and more, why not in perinatal care for the parents of extreme premature babies. A guideline also tends to leave less opportunity for patients choosing themselves.
Important to note, although gestational age (GA) is often seen as a highly accurate fact, it is not. Although other risk factors are incorporated in the new framework, we should value the fact that GA alone does not accurately predict outcome.
Not only fetal characteristics matter, personal views and circumstances of the parents can make an essential difference. A patient of 43 years, pregnant after many years of IVF will encounter risks of survival and surviving with severe impairment totally different than a patient of 21 years, accidentally pregnant during her study.
At last, we should discuss with the parents ‘what is good outcome? ’Most (future) parents, like most caregivers find severe disability the worst outcome, however some will not.
Concluding we believe it is important to boost the discussion on this difficult but very important topic by proposing a personalized multidisciplinary approach rather than using the current guidelines.
1. British Association of Perinatal Medicine. Perinatal management of extreme preterm birth before 27 weeks of gestation: a framework for practice. Oct 2019. https://www.bapm.org/resources/category/BAPM%20Frameworks%20for%20Practice.
2. Mahese E. Consider active management for premature babies born at 22 weeks, says new guidance. BMJ. 2019 22;367:l6151.
Competing interests: No competing interests