Doctors can now save very premature babies. Most hospitals don’t try.

Goines was 22 weeks into her pregnancy, just past the halfway mark. Doctors at Methodist Hospital in suburban Minneapolis said they couldn’t save such a premature baby and that no hospital could. They told her that once the baby girl was born, Goines could hold her until the infant died.

Goines didn’t want to give up. She checked herself out of Methodist Hospital and, on the recommendation of a fellow mom on Facebook, went to a birthing center connected to Children’s Minnesota hospital, 7 miles away from Methodist. After Goines gave birth, doctors there immediately intubated the baby to help her breathe and placed her in an incubator.

Me’Lonii is now a healthy 4-year-old, and has surpassed all the developmental milestones for her age. “She’s doing wonderfully well," said Dr. Thomas George, who directs the Children’s Minnesota neonatal intensive care unit.

Medical advances over the past several decades have given hospitals the ability to save younger and younger premature newborns. Yet most hospitals don’t try—and parents often aren’t aware of what’s possible or that other hospitals, even just a few miles away, might offer their newborns a fighting chance.

Doctors are now capable of saving the lives of babies born at 22 weeks and, in rare cases, a week earlier, with improved techniques to help tiny lungs develop and protect fragile skin and organs. Hospitals with extensive experience resuscitating extremely premature babies report survival rates as high as 67% for babies born at 22 weeks.

Some U.S. hospitals aren’t sufficiently equipped or capable of pulling off the new advances. Others have chosen not to offer the care, saying it is likely to fail, is expensive—typically more than $100,000 a child, and sometimes much more—and subjects tiny, fragile infants to needless pain and the risk of long-term disabilities.

Instead, they often provide comfort care: wrapping the newborn in a blanket, placing it on the mother’s chest and sometimes giving medicines to ease the child’s final moments.

The difference can be a matter of life or death for the roughly 8,000 infants born between 22 and 24 weeks gestation in the U.S. each year.

Doctors agree that babies born at 25 or 26 weeks can and should be treated as long as they don’t have other complications, while those born at 20 weeks or less are too small to save.

In between is a “gray zone," as doctors call it, where newborns’ fate can depend on which hospital happens to be delivering.

A spokesman for Methodist Hospital, where Goines first went for care when her water broke, said, “Our team thoughtfully communicated the options available to her." The hospital said it attempted to arrange a transfer at her request, but failed, the spokesman said.

After Me’Lonii was born, in 2020, she stayed in the neonatal intensive care unit at Children’s Minnesota for about four months. Doctors helped her learn to breathe on her own, closed a hole in an artery near her heart and watched her gain weight. Parents should know extremely premature babies can survive and certain hospitals will pursue lifesaving treatment, Goines said.

“At least give the parents that fighting chance," she said.

Never thought possible

In 1963, Jackie Kennedy gave birth at 34 weeks to a boy who lived for two days. Doctors then had few tools and little knowledge for how to help such premature babies survive.

Over time doctors fine-tuned equipment to keep babies warm, sometimes wrapping them in plastic. The doctors learned to give steroids to mothers about to deliver and a chemical, called surfactant, to babies to help premature lungs develop. Doctors modified ventilators meant for adults and later invented devices just for premature infants.

“Through my career of more than 40 years now we’ve seen the limit of viability move about a week every 10 years," said Dr. Edward Bell, a neonatologist at the University of Iowa hospital, a leader at treating extremely premature babies. “We’ve done what we thought was never going to be biologically possible."

Still, saving a child born at 22 weeks is difficult. Their mouths and airways are small, making it difficult to intubate them. Their outer layer of skin is often only a few cells thick. Their guts are thin and can develop holes. They have trouble regulating their body temperature and often fall prey to hypothermia. They usually need months of treatment.

The University of Iowa hospital offers parents the option of either active treatment to try to save the baby or comfort care to those born at 22 weeks. The vast majority choose active treatment. Out of those it tries to keep alive, 62% end up going home. The hospital has even graduated several 21-weekers from its NICU.

In Japan and Sweden, treating babies born at 22 weeks is more common, and in some hospitals, every single 22-weeker is treated. Some 63% of babies born at 22 weeks and treated in Japan survived long enough to be discharged from the NICU and go home, according to a study published this year in the BMJ, a U.K. medical journal. In Sweden, the rate was 58% survival until the first birthday, according to a paper published in the journal JAMA in 2019.

Rates are generally lower at U.S. hospitals that offer the neonatal treatment, according to doctors and studies, though some report comparable rates. At Children’s Minnesota, about 60% of its 22-weekers go home after NICU stays. The USA Health Children’s & Women’s Hospital in Mobile, Ala., which has been treating 22-weekers for 24 years, saves 67%.

The gray zone

Despite the progress, less than half of American NICUs—45%—provided treatment to babies at 22 weeks, according to a study of a sample of hospitals published this year in the journal JAMA Network Open.

Some hospitals simply can’t. NICUs are classified into four levels, depending on the type of care they can provide, with only Levels 3 and 4 equipped to treat babies born before 32 weeks. Even some of the higher level NICUs aren’t caught up on what is now possible or how best to care for such small babies.

Keyanna Chimilio, a flight attendant from Charlotte, N.C., was 22 weeks and 4 days along in her pregnancy in 2021 when her water broke unexpectedly. Her husband rushed her to Atrium Health University City, which has a Level 3 NICU.

Atrium staff told the couple there was nothing they could do for her baby because she hadn’t reached 23 weeks in her pregnancy. If she were just three days further along, “of course they would intervene," she recalled them saying.

Chimilio’s family, which came to the hospital, asked about a transfer. Doctors said no, she recalled. Her baby, they said, would be too small to survive.

Chimilio’s baby, named Kedrick Isaias, was born the next morning at 22 weeks and 5 days gestational age, according to medical records. He lived for about four hours.

Novant Health Presbyterian Medical Center, also in Charlotte and 12 miles away from Atrium, offers treatment to babies born at 22 weeks. Last year, a baby was born at Novant three days younger than Chimilio’s baby. The baby spent about five months in the Novant NICU. During that time, she fought off a Covid-19 infection.

Kaleigh Hughes is now home. To date, the only lasting complication is that she is small for her age, said her mother, Shontegra Hughes.

Atrium said it said it wouldn’t have been appropriate to transfer Chimilio because she was in active labor when she arrived. It said it offered Chimilio and her baby the correct care.

Extremely premature babies who survive during the initial hours following birth may die a few days or weeks later. Their survival depends not just on their gestational age, but also their birth weight, sex, whether they are a twin and other factors.

Those who survive can develop vision problems or blindness from their retinas developing abnormally. They may need extra oxygen or feeding tubes at home. Longer term, they might have developmental delays and fall behind their peers in crawling, walking and talking. Some might never catch up.

In a group of more than 10,000 babies born between 2013 and 2018 at 19 U.S. academic medical centers, about 30% of those infants offered medical treatment at 22 weeks survived long enough to go home from the hospital, according to a 2022 study in the journal JAMA.

Roughly half of 29 of those children who were evaluated at two years of age had severe or moderate neurodevelopmental disabilities, while the other half had no or mild disabilities.

Joe Kaempf, a neonatologist with Providence Health System in Oregon who treated premature babies for nearly 30 years, said the survival and disability data isn’t good enough to justify hospitals routinely offering treatment to babies born at 22 weeks. Newborns who do go home may become “a child with an IQ of 60 who will never live independently," he said.

He worries that families may feel pressure from doctors, nurses and their hospitals to pursue treatment. The hospitals are “taking advantage of the innate goodwill of pregnant women," said Kaempf, who now has a job improving hospital quality.

Supporters of caring for extremely premature babies say that while there are risks, results are now so good at some hospitals that doctors can no longer say treatment is futile simply because a mother is only 22 weeks along. They criticize drawing hard lines on providing treatment based on a baby’s gestational age, because it is inexact and notoriously unreliable. A child with a gestational age of 22 weeks might really be a week older.

It’s hard for parents to know which hospitals offer treatment to 22- or 23-week babies. The U.S. doesn’t have a comprehensive public list. Even for medical professionals, there’s no database that says what certain hospitals offer.

A Facebook group known as TwentyTwo Matters has compiled a Google map of hospitals known to have offered medical care to babies born at 22 weeks. That doesn’t mean hospitals will automatically offer care again, said Amy Hyde, one of the group’s leaders, but families can use the information to advocate for themselves.

No way to know

Rachel Sherman, a hairstylist who now lives in Florence, Ariz., wishes she had had more information.

When her water broke at 22 weeks pregnant in 2021, while she was living in Utah, the first Salt Lake City-area hospital she went to told her they couldn’t help until her baby was 24 weeks. She and her husband drove about 30 minutes to the University of Utah Hospital instead. It has a Level 3 NICU and shares a campus with a children’s hospital with a Level 4 NICU.

The staff there also told Sherman it wouldn’t save a 22-week baby and there wasn’t a neonatal unit in the U.S. that would treat an infant under 24 weeks, she recalled. But another hospital within half an hour’s drive was offering active treatment for babies at 22 weeks that year, The Wall Street Journal confirmed.

The doctors at Utah didn’t want to delay Sherman’s birth. They told her, according to notes written in her medical record, about the risk of infection and said the American College of Obstetrics and Gynecology recommended delivery. Sherman and her husband, worried that she could die, decided she should take drugs to speed her labor.

“I don’t necessarily feel like it was an informed decision because I was told there was no such thing as a NICU that would assist at 22 weeks. I didn’t know it was an option," she said.

The Utah hospital, which declined to discuss Sherman’s case, said it follows national guidelines from ACOG.

The guidelines say doctors should consider talking to parents about whether or not to treat babies born at 22 weeks. The guidelines also say doctors can, in cases like Sherman’s, offer a wait-and-see approach that would allow patients to stay pregnant as long as no concerning symptoms appear.

When Sherman delivered, the hospital didn’t send an obstetrician or nurse to her room to assist in the birth, leaving her alone with her husband, father, mother and stepmother. Staff there said they would let the infant “drop out," and that the family should page the nurse when he was out, Sherman recalled. Her son’s arm came out, but he was stuck, then stopped moving. “I felt him die," she said.

Oliver Lewis Sherman was recorded as a stillbirth. The hospital gave her a resin keepsake of the baby’s footprint.