The MedMal Room: When Born “Too Early” No Longer Means “No Chance”

Survival once thought impossible before 24 weeks is now a real—though fragile—possibility at 22 weeks. The definition of “viability” must evolve with honesty, evidence, and compassion.

Nov 04, 2025

Not long ago, a baby born before 24 weeks’ gestation was considered nonviable. “Too early to live,” physicians said quietly in delivery rooms, preparing families for the inevitable. Today, that boundary has shifted. In the world’s most advanced neonatal centers, babies born at 22 weeks—barely halfway through pregnancy—are now surviving. What was once unimaginable has become possible, though not guaranteed.

This shift matters not only for neonatologists but for obstetricians, ethicists, and parents facing the hardest decision of all: whether to attempt intensive care for a baby still smaller than the palm of a hand. “Viability” is no longer a fixed line. It is a moving threshold shaped by science, systems, and the will to give a chance.

What the new data show

A major JAMA Pediatrics study published in 2025 examined 5,019 infants born between 22 and 23 weeks’ gestation across 11 international neonatal networks covering 12 countries: Australia, New Zealand, Brazil, Canada, Finland, Israel, Japan, Spain, Sweden, Switzerland, Italy, and the United Kingdom.

The results redefine what periviability means:

Survival to NICU discharge ranged from 9%–64% at 22 weeks and 16%–80% at 23 weeks, depending on the country and level of care.
Severe brain injury (IVH or PVL) occurred in 24%–65% at 22 weeks and 18%–56% at 23 weeks.
Survival without severe brain injury ranged from 7%–53% and 9%–69%, respectively.
Among survivors, retinopathy of prematurity requiring treatment affected 32%–57% at 22 weeks and 16%–48% at 23 weeks, while bronchopulmonary dysplasia occurred in 64%–88% and necrotizing enterocolitis in 6%–28% at 23 weeks.

Countries like Japan, Sweden, and Germany now report survival rates approaching 50–65% at 22 weeks and up to 80% at 23 weeks, reflecting decades of coordinated maternal–fetal and neonatal care.

In contrast, in less developed or resource-limited regions, survival before 28 weeks often remains extremely low or effectively zero due to lack of neonatal intensive care capacity, absence of antenatal steroids, and delayed resuscitation.

What makes the difference is not only equipment but expertise. When a neonatologist is present at birth, outcomes improve dramatically. Immediate stabilization, gentle ventilation, thermal management, and early surfactant can mean the difference between life and death. Even within high-income nations, survival at 22 weeks closely tracks whether the delivery occurs in a tertiary center with 24-hour neonatology coverage.

Simply put: where and how a baby is born—and who is there—decides whether that baby lives.

The decision no parent should face alone

When labor begins at 21 or 22 weeks, parents face a decision no one is ever prepared to make: whether to request neonatal resuscitation or allow nature to take its course. That conversation, often held in the blur of fear and contractions, carries lifelong moral weight. Some families choose full intervention; others choose palliative comfort. Both decisions are valid—but only when made with accurate, current information and compassionate guidance.

We have previously published a paper called: “Advocating for neonatology presence at births between 20 and 25 weeks of gestation” arguing that neonatology attendance should begin at 20 weeks’ gestation, not 22, because even with the best dating by ultrasound, gestational age estimates can be off by one to two weeks.

In practice, this means that a baby thought to be 20 or 21 weeks could in fact be 22 or 23—the difference between presumed futility and possible survival. Waiting until 22 weeks to call the neonatologist may already be too late. Presence at the threshold of viability ensures that no potentially viable baby is left without a chance simply because of dating error or delay in response.

What “viable” really means

For decades, viability was a legal and ethical boundary: the point at which a fetus could survive outside the womb. But this study shows viability is not a number, it is a system. In Japan and Sweden, where standardized early intervention and full neonatal care are offered from 22 weeks, survival now approaches levels once seen at 24 weeks. In other regions, where resuscitation is withheld or NICU access is limited, survival remains near zero.

Parents must be told this truth. A baby born at 22 weeks and 0 days now has a real, if small, chance of survival, and with skilled, immediate care, that chance improves. Equally, families must understand that survival often comes with major medical complications, and that “survival” and “healthy outcome” are not the same.

Why informed consent matters

No mother or father should ever be told “there is nothing we can do” without knowing that, in some places, there is. Counseling about periviable birth must be transparent, balanced, and current. Doctors have a moral and professional duty to give accurate data, not old assumptions. Whether families choose comfort care or intensive care, the decision must be informed by reality, not geography or bias.

The ethical challenge is no longer whether we can save a 22-week baby. It is whether we can ensure parents understand what “saving” means: the interventions, the risks, the suffering, the hope, and the lifelong implications.

The new frontier of viability

The shift from 24 to 22 weeks is not just a medical milestone, it is a moral one. Every week, sometimes every day, now matters. This study reminds us that survival and outcomes depend as much on systems and attitude as on technology. Antenatal steroids, skilled resuscitation, and coordinated maternal-fetal care can transform what was once “futile” into possible life.

When we redefine viability, we redefine responsibility. The line has moved, and so must our honesty, our counseling, and our compassion.

There are many reported malpractice cases in the US involving allegations of mismanagement in cases of preterm births that exceeded $100 Million.

Because many survivors at the limits of viability experience neurologic or developmental impairments, physicians and institutions must be able to demonstrate that care decisions, whether to intervene or provide comfort care, were made in accordance with established policy, current data, and documented informed consent. In the absence of such structure, clinicians face a dual risk: moral uncertainty and medicolegal vulnerability. Being able to show that decisions were evidence-based, deliberative, and properly recorded is the strongest defense against later allegations that the hospital “did too much” or “did nothing.” Viability is no longer an abstract concept; it is a medicolegal responsibility that demands foresight, documentation, and consistency in every delivery room

Hospitals must have clear, written protocols for managing potential deliveries between 20 and 25 weeks’ gestation (or for that matter any preterm birth), addressing neonatal attendance, resuscitation decisions, and parental counseling. These protocols protect both patients and providers by ensuring consistency, documentation, and ethical transparency. .

Viability at 22 weeks is no longer science fiction. But every survival begins with a choice, to try. The question for medicine is not whether we can push the limits of life, but whether we can do so transparently, equitably, and humanely. How we define “possible” will reveal who we are.