Septuplets and Medical Ethics

Septuplets and Medical Ethics

The ultrasound showed seven babies. Septuplets, the doctor told the mother, and the odds against their survival were "astronomical." She could, of course, choose to abort some or all of the seven fetuses. But Bobbi McCaughey, 29, an Alberta-born seamstress living in Carlisle, Iowa, decided to let a higher power take charge of the hazardous pregnancy that had begun with fertility drugs. The devout Baptist simply prayed and, with the support of her husband, Kenny, 27, and a protective circle of family and friends who kept her astonishing secret, spent nearly six months confined to bed, waiting and watching her waistline stretch to 52 inches. "God gave us those kids," McCaughey said last month when word of her multiple pregnancy began leaking out. "He wants us to raise them."

Last week, McCaughey (pronounced McCoy) defied the odds, delivering seven babies by caesarean section, two months before her due date. The four boys and three girls - Kenneth, Alexis, Natalie, Kelsey, Brandon, Nathanial and Joel, born between 12:48 and 12:54 p.m. on Wednesday at the Iowa Methodist Medical Center in Des Moines - went straight into medical history books. Weighing just two pounds, five ounces to three pounds, four ounces each, they are the only living septuplets in the world. Said Dr. Paula Mahone, who helped deliver them, "It strikes me as a miracle."

Among the first to send congratulations were the three surviving Dionne quintuplets - once touted as Canada's miracle babies. Their birth, near North Bay, Ont., in 1934, also grabbed the world's attention. During their early childhood, thousands of tourists lined up each day and paid money to watch the girls - the first quintuplets known to live beyond infancy - on display behind a glass panel in a provincially run facility known as Quintland. But since the 1960s, when doctors began to treat barren women with fertility drugs, multiple births have become much more commonplace - to the point that several sets of quintuplets now lead anonymous, unremarkable lives.

Septuplets, however, are another matter. Just the notion of seven babies born together still has the power to astonish and to evoke enormous curiosity, delight and consternation. Friends and neighbors in Carlisle, a bedroom community 15 km outside Des Moines, are rallying around the McCaugheys, showering them with gifts and good wishes. But many specialists in the medical community are appalled that a fertility treatment had such an extreme outcome. "We are really happy that all those babies made it," says Dr. Cliff Librach, a fertility specialist at Women's College Hospital in Toronto. "But this is something you really want to avoid - it is so dangerous for the babies and the moms."

The births led to new pressures for controls on reproductive technologies that are pushing the limits of the human body. "We are not built to have such a high order of pregnancy," says Dr. Patricia Baird, who headed Canada's 1994 Royal Commission on New Reproductive Technologies. That report - never acted on by the government - recommended controls on fertility treatments to limit the number of fetuses to three. Baird, and others, argue that society cannot afford to pay for the consequences of multiple pregnancies. Many of the babies, if they survive, are permanently damaged, physically or mentally, suffering chronic disabilities and medical problems, as well as difficulties at school. "People look at the little babies," says Baird, "and forget that there will be a cascade of consequences for the family and society."

But such thoughts were far from Bobbi McCaughey's mind on Friday as she held one of her new babies for the first time. The others are still in incubators, and she and her husband are allowed to touch them from time to time with gloved hands. But after two days, doctors allowed her to pick up the largest of the septuplets, Kenneth, for a brief cuddle. "It was so unexpected," the exhausted, tearful mother told a news conference later. "We didn't think he would come off the ventilator so soon. I can't wait to hold them all." Kenneth's six siblings remained in "serious" condition - a step above the life-threatening "critical" level - but they were all faring remarkably well given their prematurity.

The precedents, however, are not encouraging. Only one other set of septuplets has ever been born alive, in Saudi Arabia in September, and six have since died. A California couple produced North America's last septuplet birth in May, 1985. One was stillborn, three died after 19 days and the survivors have medical and developmental problems. In January, one septuplet born to a couple in Mexico was stillborn - the others soon died. And last year in England, a woman expecting eight babies signed a lucrative contract to tell her story to a tabloid, but lost the fetuses to miscarriages.

Still, doctors at the Iowa hospital remained optimistic about the McCaughey brood. Because their mother was able to carry them for nearly 31 weeks - unusually long for so many infants - the babies reached a viable weight and stage of development, with well-formed hearts and kidneys. The infants' size is "wonderful" and "virtually unheard of in a multiple pregnancy," reported one doctor. But the danger, say some experts, is that some disabilities may not become apparent for years. Blindness, chronic lung problems and learning disabilities are common among premature infants. "I don't wish them any harm," says Dr. Arthur Leader, chief of reproductive medicine at the University of Ottawa. "But the literature suggests that children in multiple births will all have some form of handicap."

Many fertility specialists believe that doctors could - and perhaps should - have intervened to prevent McCaughey's potentially dangerous multiple pregnancy. "I am delighted that people are happy," says Leader. "But obviously, the lady was overstimulated by drugs." Many women are unable to conceive because their ovaries fail to ovulate - that is, produce an egg. Specialists may prescribe fertility drugs - as they did for McCaughey - to stimulate the ovaries to produce an egg during the monthly cycle. Once an egg is ripe, a second drug is injected to prepare it for fertilization - either naturally, as with the McCaugheys, or by artificial means.

But the drugs sometimes cause the production of several eggs which, if fertilized, become a multiple pregnancy. In many cases, doctors intervene to prevent fertilization when monitoring identifies more than one egg. "The solution is to withhold the ovulation drugs and advise the woman not to have intercourse during that cycle," explains Leader. Doctors later reintroduce the drugs at a lower dose. Another way to handle an oversupply of eggs is in vitro fertilization, an invasive procedure that involves removing the eggs from the woman's body, fertilizing them in a test tube, then reimplanting one or two. But to ensure a successful outcome - and to avoid the possibility of having to repeat the expensive process - some doctors insert as many as three or four fertilized eggs, especially in older women.

The technology is not perfect and, even with constant monitoring, some women end up with more than one developing fetus. Dozens of women who turn to the 25 or 30 fertility clinics across Canada find themselves in that position. Early this year, eight weeks into her first pregnancy, an ultrasound revealed that Dianne Walls, a Waterloo, Ont., customer service representative, was carrying four fetuses. "It was overwhelming," she recalls. "I called my husband at work and he went silent, he didn't know what to say." A specialist counselled the Walls on the potential risks to mother and babies. The doctor gave her an option, blandly called "selective reduction" or "fetal reduction." That entails the injection of a fatal solution of potassium chloride into the heart of one or more of the fetuses, to improve the chances of the survivors. But the Walls rejected the procedure because of the risk - estimated at five per cent - of aborting all the fetuses. "Thank goodness, it turned out all right," says Walls, who delivered four healthy babies by C-section on Aug. 25. Although she has several volunteers to help with two dozen bottles and diaper changes a day, Walls says, "I can't imagine three more."

Critics argue that, in fact, the Walls and, to a much greater extent, the McCaugheys, took an enormous gamble that could have resulted in the loss of all of the babies. Doctors understand the emotional dilemma of women facing a multiple birth. "They are torn," says Dr. Alfred Yuzpe, head of the Genesis Fertility Clinic in Vancouver. "They had trouble getting pregnant, they want to be pregnant and suddenly they have to consider selective reduction, and God forbid if something goes wrong with the remaining fetuses." But many specialists will not give fertility drugs to women who do not agree to eliminate fetuses in the event of multiple pregnancy. And most make a clear distinction between selective reduction and abortion. "I don't consider [reduction] as abortion per se," says Librach. "I look at it as a preservation of a pregnancy that would likely not survive."

As for the McCaugheys, their focus is firmly on seven new babies who may be ready to leave the hospital in January. How will they cope? "We're just trusting in God," says Kenny, a billing clerk at an automobile dealership in Carlisle. Within days of the births, the family received a 12-seat van and promises of free diapers, groceries and a larger home to replace their modest, two-bedroom bungalow. Two banks were accepting donations for the family. McCaughey said his biggest concern was to make sure his family did not turn into "a big show." The surviving Dionnes, Annette, Cécile and Yvonne, now 63, understand that worry. In poor health and near poverty, they share a home near Montreal. With their best wishes they sent the McCaugheys a book about their own unhappy lives, and some advice: not to let anyone make their babies a tourist attraction.

Friends in Alberta

In Three Hills, Alta., they remember Bobbi Hepworth fondly as a vivacious and energetic young bible college student, always in the middle of things. "Not so much a leader, but someone who was very involved with her fellow classmates," recalls Glenn Flewelling, head of the missions department at the Prairie Bible College, where she studied from 1986 to 1988. "If someone can handle this, then Bobbi's the one because she knows her God and that's very vital."

"This," of course, is the birth last week of septuplets to Bobbi (now McCaughey) and her husband, Kenny, in Des Moines, Iowa. For Bobbi, the choice of the college in Three Hills, a community of 3,300 about 100 km northeast of Calgary, came naturally - she was born there in 1968. Her American parents, Bob and Peggy Hepworth, met and married while studying at the same school. Two months after Bobbi's birth, the Hepworths moved to Michigan.

But Bobbi returned as an 18-year-old student. And she still has relatives in the area - her father's brother, Henry Hepworth, and his wife, Diane, live 60 km northwest of Three Hills, in Innisfail, Alta. "My husband talked to her on the phone the night the babies were born," says her aunt. "We called right to her room at the hospital. She said she was overwhelmed by what happened, was very tired and glad it was over with. And she had no fear for her babies, because they were all doing so well."

Diane Hepworth says her niece takes things in her stride. "I can't think of a better kind of person to handle what's happened," she says. Michelle Crouch, 29, a music teacher at the bible college, has much the same impression of the woman she knew as a fellow member of a singing ensemble at the college. "Bobbi was very unflappable, a sort of deal-with-what-happens kind of person," says Crouch. "When you think of her situation, she has the character that makes her better suited than most of us to deal with it."

According to Flewelling, the new parents can rely on family and friends to step in if public pressures become unbearable. "If people become intrusive, a wall of people will come around to guard them," he says. "If there are abuses to this family, voices will be raised."

Maclean's December 1, 1997