When a baby is born at the edge of viability, parents and doctors must weigh the chances of survival against the risk of long-term disability, the mother's health, family values and the medical resources available.
By Dr Joan Okemo, Consultant Obstetrician-Gynaecologist at Aga Khan University Hospital
For most families, pregnancy brings the hope of welcoming a healthy baby. But when a baby arrives months before the expected delivery date, hope can quickly give way to fear, uncertainty and heartbreaking decisions.
For parents facing what doctors call periviable birth, the questions are difficult: Should doctors attempt to save the baby through intensive treatment? What are the chances of survival? And how should the medical team balance the baby's needs with the mother's health and safety?
'Perivivability' generally refers to the period between 20 weeks and 24 weeks and six days of pregnancy. At this stage, survival outside the womb is uncertain, and babies face a high risk of death or serious lifelong complications. Outcomes vary, making these cases some of the most challenging in obstetric care.
Several factors can trigger very early birth, including spontaneous preterm labour, premature rupture of membranes and cervical insufficiency. In some cases, doctors may attempt a cervical cerclage, a procedure that uses a stitch to help keep the cervix closed, although it is not always successful.
Early delivery may also be necessary to protect the mother's life. Conditions such as severe pre-eclampsia, eclampsia, serious bleeding, maternal sepsis and certain heart or kidney diseases can make continuing a pregnancy dangerous. Severe fetal growth restriction, congenital abnormalities, fetal distress and intrauterine infection may also necessitate early delivery.
Multiple pregnancies, smoking, substance use, poor nutrition, short intervals between pregnancies, psychosocial stress and limited access to antenatal care can increase the risk of very early birth. These factors should not be used to blame mothers but should reinforce the need for accessible antenatal services and early detection of pregnancy complications.
When a baby is born at the edge of viability, parents and doctors must weigh the chances of survival against the risk of long-term disability, the mother's health, family values and the medical resources available.
One of the hardest decisions is whether to attempt resuscitation and intensive treatment or provide comfort care. For parents, these are deeply personal choices made during a time of fear and uncertainty.
Some families may choose intensive treatment in the hope that their baby will survive, while others may consider comfort-focused care more appropriate given the baby's condition and the likely burden of treatment. Neither decision should automatically be viewed as a failure of love or commitment.
These choices can also change between pregnancies. Parents who previously pursued intensive treatment may make a different decision after experiencing loss, prolonged hospitalisation, financial hardship or emotional trauma. Their circumstances and experiences matter, and changing their minds does not necessarily mean that earlier counselling was inadequate.
In such situations, survival cannot be the only measure of success. Babies born this early face an increased risk of complications, including cerebral palsy, learning difficulties, chronic lung disease and sensory impairments. Families therefore need honest information about the possible outcomes, alongside respect for their hopes and decisions.
Comfort care, when appropriate to the baby's clinical circumstances, is not a lesser form of care. It can be a compassionate choice. What matters is that parents understand their options and are not pressured or made to feel guilty about the decisions they make.
The challenges also extend beyond the delivery room. Prolonged neonatal intensive care can place a heavy financial burden on families through hospital bills, transport, accommodation and time away from work. These realities must form part of discussions about treatment, particularly where financial resources and social safety nets are limited.
The emotional toll can be equally significant. Families may experience grief, anxiety and trauma whether their baby survives or not. Parents who lose a baby need compassionate bereavement care, while those whose babies survive may face ongoing medical needs and difficult adjustments at home. Partners and siblings may also be affected.
Support should therefore continue beyond the immediate medical crisis. Counselling, psychosocial assistance and follow-up care are essential in helping families navigate grief and uncertainty.
Although advances in medicine continue to shift the limits of neonatal care, they cannot eliminate the difficult choices parents face. Medical guidelines are important, but they cannot account for every family's history, beliefs and circumstances.
Healthcare professionals must combine clinical expertise with honest communication, empathy and respect for parental autonomy. Parents deserve clear explanations of the likely outcomes, the risks of treatment and the options available to them, without fear of judgement.
Healthcare systems must also recognise that quality care extends beyond medical intervention. Financial guidance, psychological support, bereavement services and long-term follow-up should be integral to caring for families facing a periviable birth.
Ultimately, there may be no easy answers when a baby arrives too early. Some families will choose intensive intervention, while others will opt for comfort-focused care. Each situation must be considered individually, with the mother's safety and the baby's best interests at the centre of every decision.
As clinicians, our responsibility is not to judge families but to walk alongside them, provide honest information and respect their choices. When medicine cannot guarantee an outcome, compassion remains essential.