Like a Virgin (28 page)

But, in most ways, the grey nurse shark nurtures its foetuses in a far less complicated manner than humans; for whom getting nutrition is not as simple as ingesting egg yolk (or siblings). For a
start, the shark does not have a placenta – the complex, specialized organ that is created from the fertilized mammal’s egg in order to sustain the embryo. Because the placenta is made
from the fertilized egg, it contains both the mother’s and the father’s DNA. Very early in the pregnancy, the placenta sends out a system of blood vessels to penetrate and dock into the
mother’s womb, through the umbilical cord. The foetus acquires oxygen and food – gets rid of its wastes – through the placenta, which should provide life support for forty weeks,
until the foetus grows and develops to a stage where it is able to perform these functions on its own. A human artificial womb would need to replicate all of the placenta’s functions, not
just the womb’s fluids, bacteria, and other stuff essential to the making of life.

Still, babies born prematurely have, for more than a century, been reared through several weeks of life despite being unable to live completely on their own. In 1975, Kim Bland became the first
child to survive after being born just six months into pregnancy. He weighed little more than a couple of hundred paperclips – and had he been born ten years earlier, there would have been no
medical efforts to keep him alive, because at that time, babies who weighed less than a kilogram (
thirty-five ounces) were not considered to be viable outside of the womb.
And on 24 October 2006, Amillia Sonja Taylor was born after less than twenty-two weeks in the womb, the youngest birth yet to survive. Born in Miami, Florida, where the law does not support the
revival of a foetus less than twenty-four weeks, she owed her resuscitation to some ambiguity around her size (she appeared to be a bit older in the sonograms), and to the fact that her parents,
Sonja and Eddie, were liberal with the truth surrounding her conception (the hospital was under the impression that Sonja was twenty-one weeks pregnant when she arrived for emergency delivery). At
birth, though, Amillia was clearly tiny: weighing less than three hundred grams (ten ounces) and measuring only twenty-four centimetres (9.5 inches) long. Her body was a snug fit in the palms of an
adult’s hands, and her feet were the size of one of the phalanges of an adult’s finger.

Both Amillia Taylor and Kim Bland were only able to survive because they were nurtured in an artificial environment already within our reach – the incubator. Like the stories of an
artificial womb, the technology and benefits of the earliest incubators were a genuine marvel to the public when they initially came into use. But then again, they were brought to the world’s
attention in a very bizarre manner.

In 1897, a German paediatrician named Dr Martin Arthur Couney moved his showcase of medical specimens from Coney Island in New York City to the Victorian Era Exhibition, at
Earls Court, London. Rather than the usual monkeys, midgets, minstrels, and Moors, visitors to Couney’s were met with a true spectacle: a room neatly arranged full of large, glass-lidded
wooden boxes, each containing a tiny baby, his ‘child-hatchery’.

The boxes were based on the original designs of the French obstetrician Etienne Stéphane Tarnier, who had realized that keeping premature babies warm was not enough; they had to be
provided with isolation, excellent hygiene, appropriate feeding, and a warm, humid atmosphere in order to survive. Tarnier had studied a warming chamber used for rearing poultry at the Paris zoo.
In 1880, he built his first enclosed wooden box for infants, outfitted with a compartment to hold a hot-water bottle that could warm the space without letting in germs. This crude incubator reduced
the mortality of premature babies by nearly one third. Thirteen years later, Tarnier’s assistant, Pierre-Constant Budin, improved the basic contraption, adding a thermostat and natural-gas
heating and more windows through which the babies could be observed – an innovation that his student, Martin Couney, must have applauded. Observed the babies certainly were – in Earls
Court alone, the display drew crowds nearly four thousand strong.

The babies with whom Couney filled his incubators had been supplied by a Berlin hospital. As they were born prematurely, they were fully expected to die prematurely, too, which released the
‘incubator-doctor’ from liability for their deaths. Yet it was claimed that every one of the babies from his exhibitions had survived. With the money he made from his various circuses,
Couney purchased more glass boxes for his hospital. His attempts to manufacture an artificial, independent environment for growing babies had proved a success.

A more technologically sophisticated means of sustaining the premature was developed in the late 1950s. This comprised a mass of machinery – plates and gaskets clamped together, with
connectors for blood and gas; stainless steel plates and bolts; fixed volume gas exchangers; pressure transducers; and water baths. This incubator was used in experiments conducted on lamb,

goat, and rabbit foetuses that were extracted very early from the mothers’ wombs. The incubator was meant to replicate the idealized environment within a
mother’s body, and the age of foetuses for which this became possible was pushed further and further towards the beginning of life. The ultimate aim, of course, was to translate this
technology into saving human babies’ lives.

A baby who is born full term, after spending thirty-seven to forty weeks in a woman’s body, should have lungs that are sufficiently developed to support breathing air by him- or herself.
The lungs of babies born at around six months, however, are prone to collapsing between breaths. This problem can be overcome by providing the baby with a ventilator, which mechanically keeps the
lungs slightly inflated between breaths, and by treating the lungs with a chemical called a pulmonary surfactant (which reduces the surface tension in the lungs) that would have been produced
naturally, had the lungs been able to develop fully in the womb.

Underdeveloped lungs are a major battle front in sustaining the very premature; indeed, newborns’ deaths because of respiratory failure have been recognized since ancient times. In the
third millennium
BCE
, the legendary Chinese emperor and philosopher Huangdi reportedly noticed that this fatal syndrome occurred more often among infants born prematurely.
Techniques for artificially reviving breathing in newborns date back to Soranus of Ephesus, who lived in the first century
CE
. Soranus even criticized ‘the majority of
barbarians’ for the evidently common practice of immersing an infant in cold water to encourage them to breathe. And in the fourth century
BCE
, the father of medicine,
Hippocrates, appears to have been the first to describe an intervention that is still in use to this day – inserting a tube into the trachea to support ventilation.

Even into the early eighteenth century, divine intervention
was mostly given the credit for successful resuscitation. From the mid-1600s, midwives were trained to use
mouth-to-mouth resuscitation as an attempt to awaken stillborn infants – with little luck. The technique seemed so clearly destined for failure that the Royal Society, dedicated to the
discussion and promotion of scientific topics, branded it nonsense, stating in no uncertain terms that ‘life ends when breathing ceases’.

Others were more scientific in their approaches, though some of their solutions were often bizarre, and certainly amusing. In 1752, for example, the Scottish obstetrician William Smellie
outlined the standard repertoire for treating apparently lifeless newborns: ‘the head, temples and breast rubbed with spirits; garlic, onion or mustard applied to the mouth and nose’.
(Smellie also advocated a form of artificial respiration, and also the application of a straight endotracheal tube for resuscitation, much as is still used today.) Doctors have pried bellows up the
nostrils; wafted brandy mist under the nose; shaken the body or swung it upside down; rhythmically pulled the tongue in and out; tickled the chest; tickled the mouth; tickled the throat; yelled.
They have also tried dilating the rectum using a raven’s beak or a corncob, and blown tobacco smoke up the rectum with a clay pipe.

Fortunately, corncobs have fallen out of fashion, and artificial respiration using a ventilator – a mechanical device that fills the lungs with air – is now the accepted course.
Unfortunately, the ventilator has not overcome one of the problems in resuscitating very premature babies: odds are that the life-saving device will irrevocably damage the delicate lungs, with
serious side effects. If the lungs are damaged, that means less oxygen gets to the brain, increasing the likelihood of mental impairment.

So doctors and scientists started looking for a method that more closely simulates how air enters the foetus’s lungs in a
mother’s womb. There, the foetus
receives oxygen through the umbilical cord via the placenta, but the lungs are filled not with air but with fluid. This amniotic fluid is the ‘water’ that ‘breaks’ at the
beginning of labour. At around six months, the foetus can use its own lungs to absorb oxygen, much as adults do, but it still continues to absorb oxygen from the amniotic fluid in which it
lives.

Naturally, when scientists came up with a gentler alternative to forced ventilation, the method they chose involved delivering liquid oxygen directly into a premature baby’s lungs. The
result is the ECMO (extra-corporeal membrane oxygenation) machine, which is essentially an artificial lung. For the ECMO to work, surgeons must attach the machine’s pump to the blood vessels
in the baby’s neck or groin. But this is not free of risk either. Using ECMO can trigger bleeding, blood clot formation, and infections, and lead to transfusion problems, so although the
chances of survival are much higher, doctors are still searching for an even cleverer technology that can circumvent the threats that arise when a mother’s womb is no longer the
foetus’s home.

Of course, the fragile state of the lungs is not the lone concern for the parent of a premature baby; the very thing that defines us as human – the brain – also needs a great deal of
medical attention. It is only at thirty-seven to forty weeks of gestation – full term – that the brain passes certain key milestones that allow it to provide support for life outside
the womb. These include greater myelination, where brain cells become coated with myelin, a substance that helps them to transmit signals faster and more efficiently – including processing
sensory information and sending directions for responses, the sort of activity that permits us to pull our hand away from a flame, and thus survive threats to life. Because the brain develops over
a more protracted timespan than the other organs, it is only in
the third trimester of pregnancy, about twenty-eight to forty weeks after conception, that the striking growth
and refinement of the brain’s wiring takes place. And because the brain is relatively immature at birth, it is more susceptible to injury from premature arrival in the outside world.

Babies born before full term will fare very differently, depending on when they are born. At thirty-six weeks, a premature baby will probably be slow to feed. Before thirty-three weeks, however,
a baby will need to negotiate more serious problems, including those immature lungs. And at twenty-eight weeks or younger, a baby will face some very significant problems – though he or she
will still have a remarkable survival rate of up to eighty percent, thanks to modern medicine.

One of the most common issues among the very premature is bleeding in the brain. Although doctors do not know exactly why this happens, it increases the risk that a child born prematurely will
sustain a cognitive or neuromotor disability, such as cerebral palsy (including the inability to walk), blindness, profound deafness or mental retardation. Forty-one percent will be diagnosed with
such an impairment by the time they reach school age, meaning that within the current bounds of care, most will face a lifetime of disability. This is compared to only two percent of classmates
born at full term.

Around five percent to nine percent of all babies in developing countries, and twelve percent of babies in the US, will be born prematurely. In some places, the increase in pre-term births is
related to an increase in the number of multiple births of babies, often conceived through assisted reproductive technologies such as IVF and ICSI. But there are socio-economic factors involved
too. For example, the average birth weight of a baby should be between three and four kilograms – from six pounds eight ounces to just shy of nine pounds. Though seven percent of babies in
the UK weigh less than 2.5 kilograms, or
five pounds eight ounces, at birth, this percentage rises to ten percent in deprived areas, such as Hackney, a poorer borough in east
London.

In Hackney, I visited the intensive care unit of a neonatal ward at a large hospital. The ward contained several rooms for the care of the very premature, and all were furnished with incubators
that contained babies of different ages. Above the clear plastic boxes (the material of choice, rather than glass and wood) were monitors, fitted with flashing lights and steady electronic beeps
that announced every heartbeat, breath, and deviation in blood pressure. Every so often, a clutch of staff clad in blue gowns would wheel in a new incubator with an even newer baby, tubes threaded
gingerly to the nose and veins to deliver essential oxygen and food. A new red-eyed parent or set of red-eyed parents would stand by, asking questions. A neonatal nurse would be assigned to stand
sentry over the box – checking, measuring, tending. The nurse would work to make the incubator cosy, humid, and homely, like the environment the baby had left behind too soon. In the smallest
of the ward’s rooms, the babies were so young that many still looked like foetuses. One in particular was mesmerizing, a perfectly formed tiny doll with translucent skin, his delicate hands
and miniature feet wriggling occasionally. It was only twenty-four weeks since he had been conceived. It felt voyeuristic – like looking inside his mother’s womb, at a being no one
should normally see for another three months. Intimate, remarkable, beautiful. And a revelation.