Like a Virgin by Prasad, Aarathi (recommended reading txt) 📕

air enters the foetus’s lungs in a mother’s womb. There, the foetus receives oxygen through the umbilical cord via the placenta, but the lungs are filled not with air but with fluid. This amniotic fluid is the ‘water’ that ‘breaks’ at the beginning of labour. At around six months, the foetus can use its own lungs to absorb oxygen, much as adults do, but it still continues to absorb oxygen from the amniotic fluid in which it lives.

Naturally, when scientists came up with a gentler alternative to forced ventilation, the method they chose involved delivering liquid oxygen directly into a premature baby’s lungs. The result is the ECMO (extra-corporeal membrane oxygenation) machine, which is essentially an artificial lung. For the ECMO to work, surgeons must attach the machine’s pump to the blood vessels in the baby’s neck or groin. But this is not free of risk either. Using ECMO can trigger bleeding, blood clot formation, and infections, and lead to transfusion problems, so although the chances of survival are much higher, doctors are still searching for an even cleverer technology that can circumvent the threats that arise when a mother’s womb is no longer the foetus’s home.

Of course, the fragile state of the lungs is not the lone concern for the parent of a premature baby; the very thing that defines us as human – the brain – also needs a great deal of medical attention. It is only at thirty-seven to forty weeks of gestation – full term – that the brain passes certain key milestones that allow it to provide support for life outside the womb. These include greater myelination, where brain cells become coated with myelin, a substance that helps them to transmit signals faster and more efficiently – including processing sensory information and sending directions for responses, the sort of activity that permits us to pull our hand away from a flame, and thus survive threats to life. Because the brain develops over a more protracted timespan than the other organs, it is only in the third trimester of pregnancy, about twenty-eight to forty weeks after conception, that the striking growth and refinement of the brain’s wiring takes place. And because the brain is relatively immature at birth, it is more susceptible to injury from premature arrival in the outside world.

Babies born before full term will fare very differently, depending on when they are born. At thirty-six weeks, a premature baby will probably be slow to feed. Before thirty-three weeks, however, a baby will need to negotiate more serious problems, including those immature lungs. And at twenty-eight weeks or younger, a baby will face some very significant problems – though he or she will still have a remarkable survival rate of up to eighty percent, thanks to modern medicine.

One of the most common issues among the very premature is bleeding in the brain. Although doctors do not know exactly why this happens, it increases the risk that a child born prematurely will sustain a cognitive or neuromotor disability, such as cerebral palsy (including the inability to walk), blindness, profound deafness or mental retardation. Forty-one percent will be diagnosed with such an impairment by the time they reach school age, meaning that within the current bounds of care, most will face a lifetime of disability. This is compared to only two percent of classmates born at full term.

Around five percent to nine percent of all babies in developing countries, and twelve percent of babies in the US, will be born prematurely. In some places, the increase in pre-term births is related to an increase in the number of multiple births of babies, often conceived through assisted reproductive technologies such as IVF and ICSI. But there are socio-economic factors involved too. For example, the average birth weight of a baby should be between three and four kilograms – from six pounds eight ounces to just shy of nine pounds. Though seven percent of babies in the UK weigh less than 2.5 kilograms, or five pounds eight ounces, at birth, this percentage rises to ten percent in deprived areas, such as Hackney, a poorer borough in east London.

In Hackney, I visited the intensive care unit of a neonatal ward at a large hospital. The ward contained several rooms for the care of the very premature, and all were furnished with incubators that contained babies of different ages. Above the clear plastic boxes (the material of choice, rather than glass and wood) were monitors, fitted with flashing lights and steady electronic beeps that announced every heartbeat, breath, and deviation in blood pressure. Every so often, a clutch of staff clad in blue gowns would wheel in a new incubator with an even newer baby, tubes threaded gingerly to the nose and veins to deliver essential oxygen and food. A new red-eyed parent or set of red-eyed parents would stand by, asking questions. A neonatal nurse would be assigned to stand sentry over the box – checking, measuring, tending. The nurse would work to make the incubator cosy, humid, and homely, like the environment the baby had left behind too soon. In the smallest of the ward’s rooms, the babies were so young that many still looked like foetuses. One in particular was mesmerizing, a perfectly formed tiny doll with translucent skin, his delicate hands and miniature feet wriggling occasionally. It was only twenty-four weeks since he had been conceived. It felt voyeuristic – like looking inside his mother’s womb, at a being no one should normally see for another three months. Intimate, remarkable, beautiful. And a revelation.

For the survival of babies born prematurely, the incubator is a triumph of bioengineering. Yet what can be achieved with incubators is still very limited. One of the paediatric consultants on the Hackney ward described how, although modern incubators look sleek and