Sunday, March 7, 2010

Stroller Parade: On Multiple Births and Ethics

I watch the endless parade of strollers pushed by mommies and nannies that makes its way down the Avenue in front of my building.  Double and even triple strollers are a commonplace on the sidewalks of the city. Twins, once a rarity, are not uncommon. The year 2006 recorded the highest birth rate for twins, double the number in 1980.

As access and demand for fertility treatment spreads, more and more infants born are twins and even triplets. As couples flock to fertility treatment, reproductive medicine doctors routinely warn them that a woman is not built to carry more than one child. That there are inherent dangers in having twins, including low birth weight and premature birth, not to mention other very serious complications, like cerebral palsy, heart defects, developmental problems, and even death.

It broke my heart recently to read a Times story where a mother describes her premature twins as looking, not like the normal babies she expected, but as “aliens.” The babies are tiny; each one weighs three pounds, one ounce. They are kept alive on respirators that force air in and out of their lungs, are fed through tubes, and attached to heart monitors. It is inconceivable that these babies do not suffer, do not feel pain. The twins were a product of in vitro fertilization. The couple opted to have two embryos implanted, although the woman was cited as an ideal candidate for a single embryo transfer. She says pregnancy had become an obsession -- as it has with many of the young couples who flock to fertility centers today. After a prolonged stay in a neonatal unit, their twins finally got to go home.  This outcome was considered a success by the clinic that helped create them, yet it traumatized the parents, not to mention the babies. In another case cited, two embryos began to develop. One died inside the womb while the other was born prematurely, weighing a little over a pound. The child survived but has significant disabilities.

Unfortunately, because fertility doctors are rainmakers these days, their success is measured by the number of births they produce. They succumb to economic pressure as couples opt to implant as many embryos as possible, in hopes one will survive. As a result, our hospital neonatal units are now facing a nightmare resulting from premature multiple births.

Because the fertility business is money-driven, the higher the numbers of births, even including unhealthy preterm births, the higher the rating of the clinic and the more business they get. In Europe, where socialized medicine is common, doctors typically initially implant only one embryo when doing in vitro.

During the last 20 years we have seen an exponential drop in infant health in this country, partly due to the rise of premature babies stemming from in vitro and multiple pregnancies. In infant health, we now rank way behind European countries. A March of Dimes study cited infertility treatment as one of the main reasons for a 35 percent increase in premature infants.

I first began hearing about fertility treatment when professional women my age who had opted out of having children then turned around and decided on a last-ditch effort to beat time.  Artificial insemination and in vitro fertilization became buzzwords for professional couples. That’s when a rise in twins, fraternal twins, that is, was first noted. I think back to the experience of a physician friend who underwent in vitro. During her pregnancy several implanted embryos began to develop. That was the first time I heard the term ”embryo reduction,” that is, a euphemism for aborting embryos so one or two could survive. The twins that resulted were nonetheless born pre-term, a little over a pound each, and spent months at a neonatal unit at the hospital.  One seemed healthy, while the other had problems, including cerebral palsy and developmental disabilities, and was sent home with a heart monitor. Then the seemingly healthy one suddenly died. At the time, I thought about this horrendous tragedy as a sad anomaly, and I could not begin to imagine the feelings of the mother.

Now, as fertility treatment has spread, we have come to take the process for granted. On this matter, technology has moved way ahead of ethics. Are we so selfish and desperate to replicate our genes at any cost, even at the cost of the health of our own children? In the process, do we not devalue the gift of life?

Finally, doctors are becoming more vocal about the dangers of the multiple pregnancies that many have come to take for granted. In fact, the new President for the American Society for Reproductive Medicine, Dr. William E. Gibbons, says the Society is continuing to refine guidelines to reduce the incidence of multiple births.

Hospitals and insurers are also beginning to look closely at the financial costs of neonatal care stemming from in vitro that can easily approach 1 million for one child. They are considering something akin to the European model.

I will end with a story of a pregnancy that ends on a note different from the scenarios described above:
I am in the hospital visiting a couple who are very dear to me. Their son was born just this morning. He looks so peaceful as he sleeps.  His father is holding him, snuggly wrapped in a receiving blanket. The father hands him to me.  The baby begins to awaken and then responds to the gentle rhythms of my rocking him. He clenches his tiny fists and unclenches them. He puckers his lips and makes a sucking motion. He is a miracle. A perfect little human being. What does he think of this world? Does he dream? I wonder. What does he dream about?  The womb?  His face is angelic. He sleeps with the innocence and calm possible only in an infant. A line from Coleridge’s “Frost at Midnight comes to mind, “My babe, so beautiful, it fills my heart with tender gladness to look at thee.” What does he feel? I wonder. Hunger? Yes. Comfort? Yes. Pain? Yes. When the nurse comes in to take a blood sample, he lets out a cry. His mommy, drained from the efforts of the day and lying on the hospital bed, takes him from me. He lies against her as he nurses, hearing her familiar heartbeat, her soothing voice. He was delivered at the hospital with a perfect bill of health, according to a scale on rating infant health at time of birth, the APGAR score, named after the pediatrician first used it. Health, the nurse tells me, is directly related to birth weight and the age of gestation. The infant was full term. Unlike the types of births we seem to increasingly hear about these days as medical technology expands, there were no complications.  His parents were worried, as many couples do, about their ability to conceive, but they did not join in the current rush to fertility treatment. Their result was a healthy normal child. It was not long before the little family left the hospital with him.

Unlike what fertility clinics seem to think with their numbers game that considers the premature births of twins and triplets a success, and so take risks with the health of our children, theirs is indeed a really good outcome. 

No comments:

Post a Comment