Is our current society ready for the use of partial ectogestation beyond medical necessity? In her final contribution to the FoHR blog, Dr. Victoria Adkins examines the challenges and conditions needed to make partial ectogestation available upon maternal request, as well as the broader issues we must address before it becomes a reality.

Although the current development of artificial placentas is targeted specifically towards improving the morbidity and mortality rates of infants born prematurely, academic discussion has considered whether the technology may become something that could relieve individuals of the demands of pregnancy. Partial ectogestation has been posited as a future childbirth choice suggesting that the technology could at some point be utilised beyond medical need, allowing pregnant individuals to elect to end their pregnancies early.

Whilst my own PhD study indicates an aversion towards the concept amongst healthcare professionals, the possibility of partial ectogestation on maternal request is not entirely implausible. Caesarean sections for example, were originally utilised to secure the life of the fetus, much like the current intention of partial ectogestation. However caesarean sections are now available upon maternal request (at least on paper if not in practice) and are considered part of the choices individuals can make along their reproductive journey. It therefore may not be out of reach to consider the same trajectory for partial ectogestation once it crosses certain thresholds. What then might those thresholds be?

Developmental outcomes

Those that have framed partial ectogestation as an extension of reproductive choice do so with the caveat that it must have been proven safe beforehand. Since the technology is aimed at improving outcomes for premature infants, the first focus of safety will no doubt be in relation to the artificially gestated entity and resulting child. Whilst this seems a clear and reasonable expectation prior to maternal requests beyond medical need, many more boundaries and thresholds need to be considered. For example, how might “safety” translate to the technology and the resulting child?

A lower boundary may simply require that the entity is not “harmed” during transfer to the artificial placenta which clearly will lead to the question of how harm is measured or defined. A higher threshold may demand that the resulting child indicates parallel or perhaps improved developmental milestones with a child born through complete human gestation or with the aid of standard neonatal intensive care. This prompts the question as to the point at which development is measured- immediately after birth (however that is defined with an artificial placenta), on a weekly or monthly basis? Further to this, what type of development will be reviewed and contrasted? Physical and/or cognitive?

Making comparisons will no doubt be difficult and deciding what is or is not good enough will come with its own challenges. This is particularly the case when we consider the nuances and differentiation between children currently born prematurely and at full term, in addition to the inaccuracies of mapping gestational age. Furthermore, we do not necessarily want to eradicate those differences and there may be a danger in setting narrow “norms” that then dictate who can and cannot access the technology.

Public and private funding

Even once thresholds are decided upon and met, access to partial ectogestation beyond medical need is likely to be restricted for many. Resources will be a prominent consideration in policies that determine when and how the technology will be used, likely as it will require specialist equipment and specialist staff. In the UK context, the financial precarity of the NHS means partial ectogestation on maternal request is unlikely to be publicly funded and even if it were, the technology would likely fall victim to the postcode lottery that occurs with in-vitro fertilisation. This suggests that only certain parts of society may have access to the perceived “luxury” of opting into artificial gestation.

A significant cost-benefit analysis will be undertaken when partial ectogestation first enters clinical practice and emphasis has been placed in all debates on the technology needing to prove itself as a worthwhile endeavour. Nevertheless, the benefits that may be derived from the technology for a fetus who is facing a poor outcome with human gestation or standard neonatal intensive care is likely to be easier to substantiate than an otherwise healthy fetus that is transferred into an artificial placenta for reasons of convenience or comfort for the formerly pregnant person. However, this may prompt a consideration as to how the technology may also offers benefits for the pregnant person, who is central to the process of gestation prior to the use of an artificial placenta, and sufficient regard may finally be given to the normalised strains of human gestation.

Broader considerations

Imagining a society in which partial ectogestation is available upon maternal request is not simply a case of expanding the application of a technology. Much broader considerations need to be considered such as the way in which society itself may respond to this choice. Although a caesarean is a widely recognised form of childbirth that can be opted into, shame is still experienced by those who find themselves not being able to proceed with a vaginal birth. This is shaped largely by societal expectations of ideal pregnancies and births. Whilst partial ectogestation upon maternal request may be heralded as an expansion of reproductive autonomy, those who select this option could continue to face societal stigma.

Additionally, the availability of the technology beyond medical need may also shape how others treat pregnant people, such as employers. It could be in the interests of an employer for their employee to opt into artificial gestation- whilst they would still need to recover from the transfer, the gestational demand on the body could be significantly lessened thereby resulting in employees being out of the workforce for shorter periods. It has already been argued that any introduction of partial ectogestation as a form of gestational relief should not undermine the protection of those who do wish to continue gestation within their bodies. Therefore, we need to ensure that an expansion in reproductive choice in one domain is not met with a reduction of rights in another.

Ensuring that a perceived expansion of choice is not co-opted as a form of control will require further examination of the societal context that exists prior to introducing partial ectogestation upon maternal request. Whilst safety for the fetus may be one hurdle to overcome, much broader obstacles and implications need to be considered when considering the future of partial ectogestation.

Dr Victoria Adkins is a Lecturer in Law at University of Greenwich, and has recently completed her PhD at Royal Holloway, University of London. She would like to thank members of The Future of Human Reproduction team who contributed to a workshop discussion that led to this blog.

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