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Survival rates for babies born at 23 weeks on the rise, prompting change in definition of stillbirth

Increasing rates of survival for babies born prematurely at 23 weeks are set to lead to a change in the definition of stillbirth in Ireland.

In Ireland, a stillbirth is currently defined as when a baby is delivered after 24 weeks or more of pregnancy and is not born alive. This definition was based on a previous clinical recommendation that the threshold for viability was 24 weeks gestation.

This is differentiated from a miscarriage, which is the loss of a baby during the first 23 weeks.

Health Minister Stephen Donnelly has said that the threshold for foetal viability should be lowered from 24 to 23 weeks’ gestation following a new assessment of the threshold of foetal viability. Around 300 babies die by stillbirth every year in Ireland, according to the HSE.

Minister Donnelly said that he had been advised that the survival of premature babies born at 23-weeks gestation had improved both nationally and internationally.

“Increasingly, infants born at 23-weeks gestation are being offered resuscitation and neonatal intensive care. This is the experience both in Ireland and in other developed countries,” Mr Donnelly said last week in a written response.

He said that in that context, the HSE and the Royal College of Physicians in Ireland have produced a framework document in relation to the management of extreme pre-term birth.

“The framework document recommends that the threshold of foetal viability should be reduced from 24 weeks gestation to 23-weeks gestation,” he said.

This will replace the previous consensus document from 2006 – which stated that the threshold for foetal viability was 24-weeks gestation.

“As such, I am proposing to amend the definition of stillbirth to change the gestational age from 24 weeks to 23 weeks, along with a corresponding reduction in the existing weight criteria in the definition of stillbirth from 500 grammes to 400 grammes,” the Health Minister said.

The proposed amendment also includes an additional provision to enable the registration of children from multiple pregnancies (e.g. twins, triplets, etc) as stillborn in circumstances where they do not meet all of the clinical criteria of a stillborn child.

Speaking in the Dáil on Thursday, Minister for Social Protection Heather Humphries clarified that the Government had given approval to draft legislation to reduce the threshold for stillbirth.

“The Government has recently given approval to draft legislation, based on clinical advice from the Department of Health, to reduce these criteria to 23 weeks and 400 grammes respectively,” she said.

“In cases of multiple pregnancies, if any child reaches the criteria for stillbirth, then any other children will also be recorded as a stillbirth, provided they each weigh 200 grams or more.”

Currently, registration of stillbirths by parents in Ireland is voluntary. The birth of a stillborn child may be registered when the baby has a gestational age of 24 weeks or more, or weighs 500 grams or more.

Minister Humphries said that she was also proposing legislative changes made to allow for increased access to the Stillbirth Register.

“Currently, only the parents of a child recorded in the register or an tArd-Chláraitheoir or a member of his or her staff can search the register. The proposed amendments will enable a broader range of staff in the civil registration service to search the Stillbirth Register along with improved access to stillbirth records.”

The proposals are being sent to the Oireachtas Committee on Social Protection, Community and Rural Development and the Islands for pre-legislative scrutiny, with the Minister adding that she will bring the legislation to the Dail once that process is complete.

“These are important changes which I hope will help families who have experienced the trauma and sadness of the loss of a stillborn child,” she said.

The threshold for foetal viability has progressively fallen over time. In the 1970s, the limit for viability was set at 28+0 weeks gestation, while in the 1980s, the survival rate for babies born at less than 28 weeks started to surpass 50%.

In the 30 years that followed, it decreased to 24+0 weeks’ gestation. More recently, a further reduction in the threshold of viability to 23+0 weeks’ gestation has been proposed by many perinatal centres and working party groups, the HSE said in its new framework document.

In 2006, the Faculty of Paediatrics, Royal College of Physicians of Ireland (RCPI) stated that ‘it is acceptable not to resuscitate newborns with a birth weight less than 500g and/or under 24 weeks’ gestation.  However, this consensus statement is now being reviewed in light of recent advances in neonatal intensive care.

The two key issues dominating the debate on fetal viability are the survival rate and the risk of long term neuro-disability.

For babies born at 23 or 24 weeks the chance of survival if they receive intensive treatment is about 50:50.

Babies born after only 23 or 24 weeks of pregnancy are not ready to live outside the womb without intensive medical treatment. Treatment for extremely premature babies involves the child being in intensive care and on a breathing machine for a period of weeks or months.

Some babies require surgery on their heart, eyes or bowel, and infants born this early can have problems which last into the early days and months, or they may go on to have lifelong problems.

About 1 in 4 or 1 in 5 children who survive at this age have very serious problems affecting their movement (cerebral palsy) or learning or both that mean they will need lifelong help and support for everyday activities, according to the NHS.

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