Did low birth weight premature babies ever survive before modern medicine?
Well the easy answer is no, not in any significant numbers. But the point of this post is to tell the improbable story of how one premature and very underweight baby did in fact survive. This story is taken from Call the Midwife: A Memoir of Birth, Joy, and Hard Times by the late midwife Jennifer Worth (née Lee; called Jenny throughout the book and in this post). And thus the other point of this post is to urge those interested in a glimpse into midwifery to read Call the Midwife. It is an enjoyable read ….er, or listen as narrated by the talented Nicola Barber…. and was made into a BBC television series which broadcast after the author’s death in 2011 (and which I have not seen).
What happened to premies before the advances of the 20th century? It is easy to assume that these babies died, period. However, this likely underestimates mothers of yore. Our story concerns Conchita Warren (a pseudonym) who was pregnant with her 25th – yes the one that comes after number twenty-four! – child. The setting is London, 1952, early December, during what is now called the Great Smog of 1952. During this infamous smog inversion, visibility was nil. But we get ahead of ourselves.
A love affair without words
Before we get to the events of the Great Smog, we need to set the stage. Jenny was working at Nonatus House (a pseduonym for the Sisters of St John the Divine where Jennifer Worth actually worked), a convent that provided midwifery and nursing care to the people of London’s East End. The community consisted of dock workers and other laborers and their families. Families were large while apartments were small and money relatively scarce. A family with 8-12 children living in two rooms with toilets and a washroom down the hall was common.You get the picture.
The people of the East End formed a strong community, friendly and genial with strong mores and entrenched ways. Jenny was regularly greeted as she rode on her bicycle or as she arrived at a home visit with “Hello lovey, how’s yourself? Come on in and get warm. How about a nice cup of tea?”
One day, Jenny was given the assignment to make an antenatal (British for prenatal) visit to a Conchita Warren who was expecting her 24th child at 42 years old. In a land of Marys, Dorisses, and Gerties, the name Conchita stood out. Jenny also had a chuckle to herself as she thought about teasing the appointment-making Sister about her numerical error; surely she meant 14. But in response to her teasing, Jenny was told that 24 was the correct number, no mistake.
Jenny made her way to the large house of Conchita Warren and found a “tawny”-skinned woman in dignified control of roughly a dozen well behaved children that milled around her. Jenny explained that she had come to examine the bedroom to ensure that it was adequate for a home delivery. No response. One of the older children said something in Spanish and her mother responded, “Sí, bebé.” Realizing that she would have to talk with Conchita through the children, Jenny decided to return that night for the obstetric examination and history-taking. She reasoned that having the children translate would be inappropriate and that it would be better to have Conchita’s husband available to translate.
When Jenny returned that evening, she found a love-filled home, teeming with the full complement of 23 children. Her first sight of Len, Conchita’s husband, was of him sitting in the kitchen, bouncing a baby on his knee as he talked to the small children that milled around. As he led Jenny up the stairs, he had words for every child they passed in the hallway – “Now then, Cyril, now then, let’s get that lorrie upstairs;” and “Good on you Pete, doing your homework” before adding to Jenny, “He’s going to be a Professor one day.” Len never stopped talking and always good-naturedly and with love.
Len and Conchita shared an intimacy that was unusual in that day and place. After Jenny’s examination, Len pulled Conchita to him and said lovingly, “There’s my Con. My gal. Hows you look lovely, my treasure.” In response, Conchita gave a soft chuckle and snuggled into Len’s arms as he kissed and petted her.
When the day came for delivery, Jenny arrived to see that Len was the one in the bedroom. Jenny had never seen a man attend a delivery – mothers, mothers-in-law, sisters, yes; but never husbands. Len not only was there but he knew exactly what to do. He handed Jenny the cord scissors, changed the sheets, brushed Conchita’s hair, and called downstairs to the older children for more hot water. He handed the bloody sheets to his oldest daughter, Liz, saying “Here, you take these and put them in the boiler, will you, love? And then a nice cup of tea, eh?”
In the next moment, all of the children came in to admire their new sister. Sensing the bliss of this close family, Jenny slipped out. Len followed her and as he left the room, the conversation that he left behind became exclusively Spanish. Len commented on how clever his children were to pick up Spanish, something he could never manage himself. At that moment, Jenny realized that she had never seen Len and Conchita talk to each other: this loving and fecund couple could not speak each other’s languages. And yet, despite their lack of a shared lexicon, Len and Conchita communicated their love to each other in clear and certain terms. Jenny even thought that this might be the secret to their long and happy union.
Jenny’s admiration for the Warrens shines through. I even had the impression that Jenny was a bit crushed out on the whole lot of them and Len in particular. Jenny become friendly with the Warren clan. The oldest daughter was a talented dressmaker who happily worked with Jenny to make her clothes and so Jenny continued to visit the Warren home periodically.
#25 arrives early
Less than a year after #24’s arrival, Conchita was pregnant again. The case was assigned to Jenny. Antenatal care went smoothly and there was no reason to anticipate any problems with #25, given the ease of #s 1-24.
As one might expect, Conchita had not had a period in years. Nonetheless, according to Conchita’s estimate, she was 7 months pregnant on one fateful day during the Great Smog of 1952. At this time, there were approximately 5 babies under the age of 5 that were in the house during the day while the other 19 kids were at school or work.
Sometime during that cold wet December day, Conchita went outside, slipped, and hit her head. When she awoke on the ground, she was cold, stiff, in pain, and in a confused state. She tried to drag herself to the house but due to the smog, she ended up moving herself in the wrong direction, farther away from the house door. Only later, when the middle children came home from school was Conchita found. She was brought inside and warmed up. Late that same night, Conchita went into premature labor, presumably triggered by the shock.
When Jenny was called, she had no idea how she could traverse the three miles to the Warren house. During smog inversions, driving was impossible unless someone walked ahead with one lantern held in front to illuminate the way, and another held behind for the trailing car to see. [And then seriously, what was the point of driving? You may as well walk.] Jenny eventually asked the police to help her with a bicycle version of the two-lantern strategy. Accordingly, two policemen on bicycles with lanterns slowly led her to the Warren house. Once there, Jenny went to work and the policemen stayed so that they could escort her back or go for help as needed.
Jenny was shocked to see the normally robust, healthy and joyful Conchita look drawn, splotchy and minimally conscious. Len sat by her side, petting her hair and softly talking to her. Regardless of the state of Conchita’s mind, her uterine contractions continued apace, coming strong and at increasingly shorter intervals. Conchita, who lay uncommunicative with eyes closed, gave birth in a burst of water, baby, blood and ragged placenta. Jenny saw at a glance that the baby was blue and scooped it along with the clotted blood and placenta into a surgical bowl that she set aside on the dresser. She quickly went back to Conchita, focused on saving her from the shock that was in danger of claiming her life, and soon. Conchita’s pulse was barely detectable. As she was changing the sheets and getting Conchita warm, she heard Len exclaim, “He’s alive!”
Jenny turned in complete incomprehension, “What?”
“He’s alive! I says. It’s moving.”
Jenny rushed from Conchita to the dresser. She looked down at the pool of blood in the bowl and saw the “blood move.” She gently picked up the baby and turned it upside down to get any fluid out of its airway. As she did so, she realized that this baby was undersized even when taking into account its two-month prematurity. A 2-month premature baby should be about 4 pounds but this one was less than 2 pounds, closer to 1½. One and a half pounds is impossibly small; when my cat Tula was 3 months old and very sickly, she weighed 1½ pounds and easily fit in my palm. Conchita’s baby’s arms and legs were the size of adult fingers and the head was smaller than a ping pong ball.
Jenny cleaned up the baby and wrapped it in a warm towel. As she did so, the otherwise inert body of Conchita asked where her baby was, “niño, niño, donde esta mi niño?” Len held the baby up in front of Conchita who battled up from the lifeless depths of her confusion, opened her eyes, and reached out a hand to touch the cherished baby while murmuring, “mi niño, mi cariño niño.” Len placed the baby on Conchita’s chest who responded by clamping a hand over the baby.
Throughout the period of labor and aftermath, more and more physicians arrived, having made it eventually through the smog to the house. A pediatrician pleaded with Len, “The baby needs to go to the hospital or it will die.” Len protested but exhortations from the various medical staff convinced him to reluctantly agree to allow the ambulance crew to take the baby to the hospital.
As the pediatrician went to take the baby from the seemingly out-of-it Conchita, Conchita held the baby more tightly and to dispel any doubt about her feelings, she placed her right hand over her left hand that held the baby. Len tried to take the baby but Conchita held fast. The physicians repeated their warning that the baby would die if he was not placed in an incubator at a hospital.
Len told Liz to tell her mother that the baby needed to go to the hospital. Liz softly talked to Conchita in Spanish and Conchita responded, “No.” Liz softly talked some more to her mom and once again, Conchita simply said, “No.” Finally Liz told Conchita that the baby “morida,” would die, if not taken to the hospital.
Conchita’s voice rose from her inert body, “no morida,” repeating over and over that the baby would not die. Another moment passed and Conchita became focused and awake, looking each of the medical professionals in the room in the eye and clearly stating [in Spanish and translated by Liz], “No, the baby stays with me, he will not die.”
The pediatrician protested, imploring Len to tell his wife that the baby could not live outside of an incubator. The baby needed specialized treatment and would receive the best treatment possible at the hospital.
Len stopped the pediatrician saying, “This is all my fault and I must apologize. I said the baby could go to hospital without consulting my wife. I shouldn’t ‘a done that. When it comes to the kiddies, she must always have the last word. And she don’t agree to it. The baby’s not going nowhere without his mother’s consent.” Len went on to say that the baby would stay at home with his mother and if he died, he would be buried.
As it turns out, no burial would be necessary. Conchita kept the baby on her chest, ensuring its warmth. The baby rode up and down with Conchita’s every breath. On that day of birth, Conchita placed a bit of colostrum (early milk, which contains antibodies) on the end of a small stick which she then placed on the baby’s lips. Later she did the same with milk. Conchita did this hour after hour, through the days and nights of the baby’s first months. In this way, she nursed a 1½ pound premature baby through several episodes of jaundice into a robust, healthy 6½ pound, 4-month old who smiled and grasped outstretched fingers.
How would a 1½ pound baby fare today?
Today, a 1½ pound baby would have a roughly 75% chance of survival but back in the 1950s, survival would not be expected. Yet, operating on instincts and her extensive knowledge of babies, Conchita Warren was able to achieve the improbable, to bring a tiny premature baby into health. And she did it in a modest home in the East End of London in 1952 with only her intuition and a couple of pieces of medical advice to go on.
The medical advice that Conchita received was 1) to turn the baby upside down after each feeding and rub his back to prevent aspiration; and 2) to use a suction tube (provided) to clear the baby’s airway when needed.
No incubator, no oxygen, no drugs. Plain old-fashioned mothering and lots of love and luck.
There are several factors to consider. First, it is likely that Conchita and Len’s baby was premature because of the mother’s traumatic fall and not because of any inherent problem that the baby had. In other words, if Conchita had not fallen and become ill, labor would not have commenced that night and the baby would not have been premature. This is important because premature babies are at a high risk for what are typically termed birth defects. [I apologize for the offensive term but I know of no other.] So Baby Boy Warren had an advantage in that he was healthy until his early expulsion from his mother’s womb.
Conchita and Len’s baby had a great disadvantage in that he was very under weight. Clinically, a baby that weighs less than 1500 grams (3 pounds 5 ounces) is considered to have an extremely low birth weight. Extremely low birth weight babies have a low survival rate and a high rate of future problems such as blindness, deafness, and intellectual disability. For example, of 86 babies, born in Cleveland in the mid 1970s, who weighed between 500 and 1000 grams (1.1-2.2 pounds), 54 (63%) died and 25 (29%) appeared healthy at two years of age (Hack et al 1979; NEJM 301:1162-65). And this study concerned babies born 25 years after the birth of Baby Boy Warren, babies that received extensive medical care in a hospital. In this light, Conchita’s accomplishment is extraordinary.
There are also caveats here, Baby Boy Warren is one anecdotal case. More significantly, we don’t know what happened to him past the age of 4 months. A significant birth defect may have become evident later on in life. Many birth defects only become apparent during infancy, childhood or even adolescence. So the fact that Baby Boy Warren made it to 4 months does not mean that he was home free. Nonetheless, he lived and given the circumstances, that is truly remarkable.
Categories: Book reviews