John Varghese

A chilling scene in Mad Max: Fury Road depicts the “Organic Mechanic” performing a C-section on a dead Angharad calling out, “Crying shame. Another month… could have been your viable human… your number one alpha prime,” as he drools and twirls the cut umbilical cord between his fingers. Contrived to shock, the scene hyperbolizes the anguish of losing a viable life to the vagaries of pregnancies.

• WHO reports an estimated 15 million (about 1 in 10) babies are born preterm.
• Preterm birth complications are the leading cause of death among children under five years of age, responsible for approximately 1 million deaths in 2015.
• Across 184 countries, the rate of preterm birth ranges from five to 18 percent of babies born.
• Three-quarters of these deaths could be prevented with current, cost-effective interventions.
• Although preterm survival rates have increased in high-income countries, preterm newborns still die because of a lack of adequate newborn care in many low-income and middle-income countries.

Pregnancy in humans normally lasts 40 weeks. Babies born three or more weeks premature, often called “preemies” by those in the field, are at significantly higher risk for a wide range of health problems. The earlier a baby is born, the higher the chances of neurodevelopmental physical and cognitive impairments, even if the baby survives. Of course, preterm birth has a sliding scale of viability, but a brutally harsh line is drawn in Canada and the U.S. for statistical purposes at week 20. Pregnancy loss up to 19 weeks and six days is classified as a miscarriage, and at 20 weeks a stillbirth.

According to an environmental scan prepared for the Canadian Premature Babies Foundation-Fondation pour Bébés Prématurés Canadiens, about 29,000 babies are born prematurely, which forms a surprising 7.8 percent of all births (as high has 13.9 percent in Nunavut!).

A premature birth can be traumatic and stressful for both the baby and family. Immediate health complications include heart issues such as an abnormal opening between the aorta and pulmonary artery, breathing issues or respiratory distress caused by underdeveloped lungs, apnea (long pauses in their breathing), brain hemorrhage leading to permanent brain injury, low core body temperature which can lead to hypothermia, gastrointestinal issues caused by underdeveloped digestive tracts, blood issues including anemia, and a weakened immune system. Some babies may require a long hospital stay (weeks or months) before they are able to go home with their families, and immaturity is the largest cause of infant death in Canada, causing approximately a third of all infant deaths. Children born prematurely also have a higher likelihood of requiring more healthcare services, psychological supports, special education, developmental services, et cetera.

Doctors cannot always find a specific cause for preterm childbirth. For example, the WHO suggests that genetic predisposition is a risk factor. Further risks might be prior history of preterm childbirth, miscarriages, or abortions; getting pregnant less than six months after giving birth; issues with reproductive organs, diabetes, or high blood pressure; lifestyle factors such as smoking, alcohol, or drug use; or experiencing a highly stressful event while pregnant, including medically indicated reasons like preeclampsia, placental abruption, and fetal distress.

Recent advancement in management of preterm births has placed some key interventions to improve the chances of survival and future health outcomes for preterm infants. Neonatal incubators have been around in neonatal intensive care units for a long time now and give preterm babies a chance at life. Incubators help with warmth (neonates don’t have much of a fat layer), extra oxygen (underdeveloped lungs), protection from light and sound (sensitive eyes and ear drums), protection from infections (underdeveloped and compromised immune system), and monitoring vitals 24/7. With improved technology, incubators are getting better at improving survivability and decreasing the risk factors of early birth for preterm babies.

In April 2017, Nature published a study on an extra-uterine support system that enabled extremely premature lambs to survive and grow outside the ewe’s womb. The team of neonatologists, developmental physiologists, and surgeons at the Children’s Hospital of Philadelphia (CHOP) who developed this technology were motivated purely by their professional desire to save lives. “Our goal is not to extend the limits of viability, but to offer the potential for improved outcomes for those infants already being routinely resuscitated,” their paper clearly says. But the study resulted in a media frenzy of slippery-slope speculation of the imminent evolution of human ectogenesis and the ethical minefield of science “creating life”!

In case of CHOP’s biobag, a sealed bag with an oxygenator circuit creates a womb-like environment replete with amniotic fluid and all necessary nutrients constantly exchanged via a cannula that acts as an umbilical cord would in the maternal-fetal system, carrying nutrients and oxygen to the lamb fetus. Successful oxygenation of the fetus is dependent on the fetus’s own heart and an oxygenator working together, which mimics normal maternal placental blood flow. The lambs were developmentally equivalent to a 24-week human preterm infant when they were placed in the biobags. After four weeks inside the apparatus, each lamb showed healthy developmental markers and was free from the common complications associated with prematurity.

The concept of an artificial womb (AW) has been studied during the past 60 years with various degrees of success starting in the late 1950s. Limitations of technology and science didn’t take this field of study far at the time. Interest abated temporarily during the 1970s because of improved neonatal care but was revitalized in recent times with simultaneous efforts ongoing across the globe. The Women and Infants Research Foundation in Western Australia published a study just months after the CHOP study came out. Its ex-vivo uterine environment (EVE) therapy has reported greater success on lambs going into the artificial environment at a human equivalency of 22 to 24 weeks and turning out stable and healthy inside the artificial womb.

Apart from the huge gaps in knowledge, the metaphysics of pregnancy is fairly nebulous and has in recent times caused debate and controversy. Similar to arguments for and against in vitro fertilization (IVF), there is an ever-present conflict between those who support and those who criticize any new technology as it relates to the sacrosanct nature of the beginning and ending of human life. The intertwinement of two separate entities (mother and the fetus) is a physiological and ethical dilemma of personhood much more profound than the mere ambiguity in ownership of the placenta and the umbilical cord. Widely accepted existing technology — the incubator — helps premature neonates to continue to develop while providing a safe space. An artificial womb is intended to facilitate exactly this process of gestation, but from an earlier point in time.

Mothers-to-be with perfectly healthy fetuses often face medical conditions requiring termination of pregnancy and would benefit from the option of preserving their pregnancy. Women diagnosed with placental insufficiency or medically indicated prognosis of dangerous last trimester also could benefit from this new technology. The possibility of completing a pregnancy from an as-much-as-possible position to full-term viability would fill with hope the lives of those families who have been pining for a child. Also falling in this category of medical necessity are candidates for fetal surgeries that could be performed with higher success and much lower risk for both the mother and the fetus if it were in extracorporeal environment. These are real-life situations of suffering and emotional distress by all parties involved across the globe and are the key factors considered when making decisions surrounding gestation, intervention, and medically appropriate care.

We are decades away from even contemplating complete ectogenesis. As this technology advances to that state where IVF and AW is combined to fertilize and grow a human entirely outside the human body we approach and stumble upon multiple technological and ethical thresholds. Social, religious, and cultural ones loom large too. One of the most important outcomes of this technology would be the emancipation of women. Linking motherhood to females is a given, and rarely considered in our existential discourse as a factor to consider. We are still a society that believes strongly that natural reproduction is an awesome part of life and women are privileged with the act of “carrying” life and giving birth. In recent times, more questions are being raised on this evolutionarily heavy burden.

Pregnancy complications range from mild to annoying to career changing to even life threatening. The rate of deaths due to obstetric causes in Canada for 2018 was 8.59 per 100,000 live births. Other lesser advanced parts of the globe have rates as high as 1200 per 100,000 live births! Infections, gestational diabetes, preeclampsia, tearing, diabetes, hypertension, placental abruption, lifelong incontinence, anxiety, and depression are all risks carried by the mothers. The male counterpart can and does contribute toward the creation and sustenance of new life by proxy but cannot physiologically assume these risks. Careers and normal activities are put on hold or sacrificed by mothers.

If the argument is that mothers make a choice to become pregnant, then they also have a right to change their minds about their bodies. Artificial womb technology, as it develops, through scientific and ethical rigor, will enable women to be freed from the risks of pregnancy. Females can then choose to be involved in the process of bringing life into existence by proxy just as men have all along. In matters of a post-pregnancy decision of life, this technology renders abortion both pro-choice and pro-life, because it enables fetuses aborted by mothers who didn’t want them in their bodies to be rescued.

This is all a long way into the speculative future world of artificial womb technology. In its current state, it is practically impossible to implicate artificial womb technology with harvesting eggs and creating life in a petri dish, removing women entirely from the propagation of the species. The entire premise of this system is based on the cardiac function of the fetus being sufficiently developed to drive the blood through the system. That is the hard-stop that abrogates any fear of full ectogenesis.

The idea of saving a latent life is an attractive one, especially when we eliminate the factor of its post-rescue viability. It gives hope to couples who would otherwise not be able to become parents and helps society consider the idea of emancipating women from pregnancy. Like all scientific advancements, there are decisions that scientists, legislators, and societies will need to make as artificial womb technology takes root. Just as we did with IVF, we will begin to look at this new technology as assisted reproduction — special for those it affects and mundane within the realms of scientific discourse.