Introduction

A normal gestation lasts 40 weeks following the mother’s last menstrual period, and prematurity is defined as a gestation lasting fewer than 37 weeks. Until the 1960s, most premature babies died. Four recent developments in neonatology – respirators, parenteral (intravenous) nutrition, antenatal corticosteroids, and surfactant replacement therapy – have improved outcomes for preterm infants. The “physiological” lower limit of viability is similar in all industrialized countries: 22 weeks gestational age with some very rare survivors at 21 weeks. There is, however, tremendous variation among countries in survival of babies at 22–25 weeks of gestation. Doctors and parents in many countries choose not to provide these infants with active interventions. Many people think that the survival rate for babies born at 22–24 weeks is too low and the rate of disabilities among survivors is too high. Some health policy makers worry about the cost of neonatal intensive care for these tiny babies. We will examine all of these issues and do so with particular attention to international variations in the treatment of extremely low gestational age neonates (ELGANs).

Case narrative

Mrs. Duran is 24 weeks pregnant. It is her first pregnancy. When she and her husband first saw the ultrasound images of their baby’s heart, her fingers, and her cute profile, they decided to call her Kim. Mrs. Duran was meticulous in following the recommendations in her baby book: no alcohol, raw meat, unpasteurized cheeses, exposure to smoke, or coffee, tea, or chocolate. She exercised 4 days each week.