For parents expecting a baby, the dream is a safe delivery and the joy of holding their newborn. But when labour begins months too early, hope can quickly turn into fear, forcing families to confront decisions no parent ever imagines making.
When a baby arrives between 20 and 24 weeks of pregnancy, survival is uncertain, the risk of serious complications is high, and parents may have to decide whether to pursue intensive treatment or focus on keeping their baby comfortable.
Dr Joan Okemo, a consultant obstetrician-gynaecologist at Aga Khan University Hospital, describes this period, known as periviability, as one of the most emotionally complex situations in medicine.
“Periviability is a time when a baby born prematurely faces immense challenges, survival is far from guaranteed, and the decisions parents and medical teams must make are among the most emotionally complex imaginable,” she says.
The dilemma is not simply whether a baby can survive outside the womb, but what that survival might entail for the child, the mother and the family.
Periviable births may result from spontaneous preterm labour, premature rupture of the membranes, or cervical insufficiency. In other cases, serious complications such as severe pre-eclampsia, maternal infection or heavy bleeding may make early delivery necessary to protect the mother’s life.
Babies born this early face a high risk of death and serious complications, including cerebral palsy, chronic lung disease, learning difficulties and hearing or vision impairments. Outcomes vary, depending on gestational age, the baby’s condition and the medical care available.
For doctors, the challenge is to explain these uncertainties honestly without extinguishing hope, while on the other hand, parents need to make potentially life-changing decisions while coping with shock, fear and grief.
“Should resuscitation be attempted? Should care focus entirely on comfort? What truly serves the best interests of both mother and child?” Dr Okemo asks.
“These are not merely technical considerations but rather, they are profoundly human ones, shaped by the weight of individual circumstances that no guideline can fully anticipate.”
Where continuing a pregnancy threatens the mother’s life, her safety must remain central to clinical decision-making. At the same time, families need clear information about the baby’s prospects and the possible consequences of intensive treatment.
It’s understood that families who have previously experienced a periviable birth, another pregnancy can reopen painful memories of prolonged hospitalisation, financial strain, disability or the loss of a child.
Dr. Okemonargues that some parents may choose intensive treatment again, while others may reach a different decision after reflecting on their earlier experience.
“Periviable decision-making is never purely clinical. It is biographical, relational, and shaped by time and experience,” Dr Okemo says.
According to the medic, parents should not be judged for choosing comfort-focused care when it reflects an informed understanding of their circumstances.
“Survival cannot be the only measure of success. Quality of life for the baby, the mother, and the entire family must be part of every honest conversation,” she says.
Comfort care is not abandonment. It prioritises the baby’s relief, dignity and family contact when intensive interventions may offer limited benefit in the circumstances.
The consequences of periviable birth often extend well beyond the delivery room, Dr. Okemo elaborates, noting that prolonged neonatal intensive care, specialist consultations, rehabilitation and developmental follow-up can place considerable financial and emotional pressure on families.
She suggests that parents may also need bereavement counselling or long-term psychological support, particularly after losing a child.
“Financial and psychosocial support are part of medical care,” Dr Okemo says, highlighting the need for healthcare systems to recognise the wider burden on families.
She also stresses that support must continue after the immediate medical crisis.
“Grief is not linear, and support must not be episodic,” she says, adding that bereavement counselling, psychosocial support and long-term follow-up are essential components of periviable care.
Ultimately, advances in medical technology may improve the prospects of babies born extremely early, but they cannot eliminate uncertainty or make deeply personal decisions for families.
For Dr Okemo, the responsibility of healthcare professionals is to offer honest guidance and compassionate support without judgment.
“The least we can offer is to walk alongside her, with honesty, compassion, and without judgment,” she says.
And for parents facing the possibility of losing a child before they have had the chance to bring them home, that compassion cannot guarantee a happy ending. But it can ensure they do not face the heartbreak alone.
