Examination of Witnesses (Questions 20-39)|
15 OCTOBER 2007
Q20 Dr Turner: Professor Wyatt, you
talk simply in terms of survival, in terms of living or dying.
Can you comment on the quality of life in terms of degree of disability
given the large number of disabilities in preterm babies of this
age? Do you have any views on the reasons why these babies are
delivered preterm so early?
Professor Wyatt: It is sadly true
that babies born around the limits of viability have a high risk
of having subsequent problems and these problems range from physical
problems, neurological problems, learning difficulties, behavioural
problems and so on. There is a large number of studies which have
been performed and are currently being performed into the long
term outcome. Again, the studies have quite a range of variations
in outcome between different studies. They vary in the precise
measures that are taken. To answer a question such as the quality
of life is very difficult. It is clear that some babies born at
the limits of viability tragically are profoundly disabled but
the evidence suggests that severe, profound disability is actually
relatively uncommon as a long term outcome. We do have quite a
large number of children who have some learning difficulties,
behavioural problems, but I would resist the suggestion that that
means their life has no value or that it is not appropriate for
us to care or to give these babies the very best chance of a good
Q21 Dr Turner: Can you comment on
the reasons for such early parturition? Do you think there is
a limit between prospective disability and early delivery? In
other words, a natural abortion, for want of a better word?
Professor Wyatt: There has been
a huge amount of research as to why babies are born very prematurely
and we know that there are a large number of factors which increase
the risk of prematurity, but it is true to say that in any group
of premature babies a very significant proportion are those in
which no reason can be identified as to why the mother went into
labour very prematurely. It is not true to say that the presumption
must be that there was a congenital problem with the developing
baby in the womb, with the foetus, which was the cause of the
prematurity. The research that goes on into the cause of injury
suggests that in the majority of cases damage to the brain and
the developing nervous system happens around the time of delivery,
sometimes immediately before, sometimes during the delivery process,
sometimes in the critical first few days of life, sometimes later
on during intensive care. These are the issues which we are trying
to address and many workers in the field are trying to address
to minimise the damage that occurs to the brain around the time
Q22 Chairman: The thesis presented
by Professor Wyatt appears to be that if you have a high quality
specialist unit the chances of surviving below 23 weeks are significantly
increased. Those were the words that were used: "significantly
increased". That is what your article said.
Professor Wyatt: To clarify, less
than 24 weeks.
Q23 Chairman: Sorry; less than 24
weeks. Is not 23 weeks less than 24 weeks?
Professor Wyatt: Yes.
Q24 Chairman: At 23 weeks. Have you
picked that up in the EPICure study?
Professor Marlow: Obviously the
data are still being analysed at present.
Q25 Chairman: I do not want you to
reveal the data. Just give us the facts.
Professor Marlow: In effect I
can see no statistical improvement in survival at 23 weeks from
the preliminary analysis we have had of the data.
Q26 Chairman: Is that on individual
Professor Marlow: We have not
looked at those data yet. That is something that we will do some
time down the line but we have not had a chance to analyse survival
by unit. To my mind, there is no incompatibility between what
I have said and what Professor Wyatt has said. In medicine we
always need centres of excellence that are pushing boundaries
back and are leading the way forward for many of us to follow
often. It is very important that, if units have a philosophical
agreement with starting care at very low gestations, they should
try and provide the care to their ability. That is likelyand
I think there is evidence from other countriesif followed
through to produce improved survival. One of the problems is of
course that the rates of disability at low gestations do rise
quite steeply. Down at 25, 24 and 23 weeks we are certainly looking
at about 25% of the population who will have serious, life long
Q27 Chris Mole: Professor Marlow,
you obviously cannot reveal what is going to be in EPICure two
but in terms of our inquiry which is scientific developments since
1990 primarily is the original EPICure study still relevant for
people to take into consideration or is it becoming out of date?
Professor Marlow: I think the
survival rates are becoming out of date. If you look around the
world at very low gestations, there is very little evidence that
any of the rates of disability differ between different countries.
We recently compared the outcome in a very low gestation in France
to ourselves and the results are identical. I have also had the
opportunity to look at data at North America. Again, when they
are defined by gestation, the rates of disability are much the
same. I am fairly confident about that. Nobody has shown really
a significant improvement in that rate of disability over the
last ten years. What we have seen, certainly in the Trent region
of the UK, are significant trends in survival at 24 weeks but
we have not seen those at 23 weeks. Even in an area which is dealing
with 67,000 births, we see an almost twofold variation in survival
at very low gestations, at 23 weeks for example, which reflects
the small numbers of children. One extra child surviving one year
pushes the figures right up. There is a lot of variability. It
happens at very low gestations and survival is mainly related
to the statistical confidence around what happens over one year.
Q28 Chris Mole: Professors Marlow
and Wyatt, are you of the opinion that there is any link between
abortion and subsequent preterm births?
Professor Marlow: Recurrent abortion
is thought to be a risk factor for preterm births. I am not an
expert in that area and I would not push that any further.
Professor Wyatt: There is scientific
evidence of a statistical association between a previous induced
about and an increased risk of subsequent premature delivery.
The problem with studies like this of course is that statistical
associations do not in themselves prove a causal link and therefore
there is a number of scientific and other questions that go on
to try to tease out the question as to whether or not there is
a genuine causal link or a statistical association. Having reviewed
the evidence myself, my impression is that there is sufficient
scientific evidence to suggest there is a causal association and
a number of large studies that have been performed have suggested
that there may be a causal link. That is, to me, the force of
the evidence, such as it is.
Q29 Chris Mole: Is there a variation
in that between one induced abortion and multiple induced abortions
and the impact on the risk of subsequent preterm birth?
Professor Wyatt: Statistically
the evidence, the majority of studies, appear to show that there
is what is called in rather unpleasant terms a dose response relationship.
If you have more than one induced abortion, it increases the risk
of a preterm delivery in a subsequent pregnancy.
Q30 Chris Mole: But one might not?
Professor Wyatt: Statistically
the majority of studies suggest that one probably does but there
are matters of scientific controversy.
Q31 Chairman: Professor Marlow, would
you support that?
Professor Marlow: I would not
Q32 Chris Mole: Professor Wyatt,
you have made some comments about an estimate of the cost of abortion
and preterm births to society. How accurately can we put monetary
terms on those sorts of issues?
Professor Wyatt: I am not a health
economist and these are very technical, complex areas. I would
not in any sense wish to. It is a study which, as far as I am
aware, has not been performed and, looking at the health economic
aspects of a whole number of factors in terms of the provision
of premature care, it is something that is important.
Professor Marlow: Not all preterm
delivery is at border line viability. The vast majority of preterm
deliveries are at later gestations where survival is very high
in most centres across the UK and the developed world.
Q33 Chairman: Below 24 weeks there
has to be a lot of intervention.
Professor Marlow: No. When you
say there is a risk of preterm birth, I would like to draw the
distinction between there being a risk of birth before 36 weeks
of gestation and birth before 24 weeks of gestation.
Mrs Dorries: The definition of preterm
is 36 weeks.
Q34 Chris Mole: One of the technological
developments that has happened over the last decade or so is the
introduction of 4D images. Can I ask all of the panel if they
believe there is anything we can learn from that that is relevant
Professor Fitzgerald: At the moment
what we can learn is very limited simply because the technique
is still under development and still really at a stage of trying
to confirm that a lot of the structures that you see are similar
to those seen in animals and other mammals, trying to identify
the different areas, but I think it is a technique that in the
future will probably be very useful for prediction of outcome
if that was what you were asking, yes, but perhaps not so much
at the moment.
Q35 Chairman: Is that generally agreed?
Professor Marlow: It is helpful
in terms of prediction of abnormality and therefore one is able
to see structures that one would not see in ordinary, two dimensional,
real time, 3D ultrasound. I do not think it tells us any more
about foetal development than we probably knew already.
Dr Spink: Would the panel accept that
4D imaging has brought about or is starting to bring about a sea
change in public attitude towards abortion since they can now
see the child developing at 18 and 20 and 22 weeks in a way that
they had not perceived before when they were thinking about foetuses
rather than real children with real limbs, fingers and finger
nails, forming a relationship with their mother, listening to
their mother's voice, even at that stage? It has caused a change
in public perception on the value of abortion to society.
Q36 Chairman: There is a significant
difference between what we mean by public perception and how we
measure it but I am sure Dr Guthrie and Jane Fisher will answer
Dr Guthrie: Certainly there is
public debate. I am a clinician. My job I suppose is to interpret
the science to the women that I see in the clinic. My women are
certainly a lot more, shall we say, informed and they are asking
a lot more questions than they used to do. That has not reduced
the number of women seeking abortions. There is something about,
yes, there is more knowledge or we think we have knowledge or
we have clues. How do we interpret them? The fact remains that
there is still a need out there for women to access services.
Despite what women know, it is very interesting that the demand
is still there.
Jane Fisher: They do provide what
are quite memorable images of a developing baby but what has muddied
the waters is people thinking we can get more clinical information
from those images and it is important to make that distinction.
Yes, the images may be very beautiful but they are not necessarily
adding any more to clinical information about developing babies.
Q37 Chris Mole: On the question of
foetal organ development, there is a lot that helps our understanding
of the concept of viability in terms of the development of the
nervous system, the capability of the lungs to function and so
on at different ages. How much has our understanding of all that
changed in the last 10 or 20 years?
Professor Fitzgerald: In terms
of 4D imaging, I do not think it has told us anything about the
development of the nervous system. An image of a body tells you
nothing about the nervous system. I think it is really important
to separate the brain from all other organs. We really will be
able to understand a lot about general organ function and dysfunction
in foetal life but we still really have no knowledge of what the
structural correlates of consciousness are. We simply do not know.
That is incredibly important. We can guess a number of things
about the development of the human brain at various stages of
gestation but it really will be just guessing. All of our functional
understanding of what infants may or may not be able to process
by the brain have been performed after a baby is born, not in
foetal life. That is an incredibly important point because the
brain in a foetus is perfused effectively by sleep inducing chemicals.
This is something that is not well understood. It is not possible
to extrapolate back from a 23 or 24 week baby, which Professor
Marlow and Professor Wyatt have been talking about, to how the
nervous system will be functioning in utero as a foetus. It is
in a completely different environment.
Q38 Chairman: How do we know?
Professor Fitzgerald: We know
that from two important areas of study. One is from work on sheep
foetuses and is by Professor David Mellor in Sydney, a huge body
of work studying all of the hormones that are perfusing the brain
in a foetal lamb and measuring brain activity over the whole gestation
period. We know it as well from the work of Professor Lagercrantz
at the Karolinska Institute who also measured equivalent hormones
in human foetuses. There is very strong evidence that the foetus
is effectively asleep. It is like you asking if a man who is deeply
sedated feels the same as a man who is not. It is that kind of
Q39 Mrs Dorries: There has been a
more recent study, has there not, in the United States that shows
perhaps the opposite of what you are saying? You said you are
just guessing and you cannot say 100% that a foetus cannot feel
and cannot respond to toxic stimuli or whatever. Therefore, if
we do not know, is it not more humane and preferable that we come
down on the side of the foetus and assume that the foetus can
feel? I ask this for a very specific reason. I was present at
two 4D screenings recently, one where a needle was inserted into
the abdomen of the mother and the baby physically recoiled from
the needle on the screening, and the other one where a baby was
simply nudged and pressed in order to change position. The baby
obviously was pulling faces and did not want to do it. Having
witnessed both of those 4D screenings of both of those babies,
one was very aware a needle was coming at it and the other was
very aware that its position was being changed. If it was deeply
asleep and unconscious, how was this foetus aware of what was
going on in utero?
Professor Fitzgerald: I think
it is important that you understand the nature of the reflexes
in an integrated nervous system. If, God forbid, you were a quadriplegic,
you were somebody whose spinal cord had been damaged like Superman's
was. It was damaged at a very high level so you could feel nothing
below the level of the lesion. You could not move and you could
not feel anything. If I then put a needle in your toe, you would
feel nothing but your whole body would recoil. The nervous system
below the level of the brain is incredibly organised.
1 Note from the witness: Referring to the actor, Christopher
Reeve, and campaigner for spinal cord injury research. Back