Obstetric violence is a misnomer.

The term "obstetric violence" has been used in the legislative language of several countries to protect mothers from abuse during pregnancy. Subsequently, it has been expanded to include a spectrum of obstetric procedures, such as induction of labor, episiotomy, and cesarean delivery, and has surfaced in the peer-reviewed literature. The term "obstetric violence" can be seen as quite strong and emotionally charged, which may lead to misunderstandings or misconceptions. It might be interpreted as implying a deliberate act of violence by healthcare providers when mistreatment can sometimes result from systemic issues, lack of training, or misunderstandings rather than intentional violence. "Obstetric mistreatment" is a more comprehensive term that can encompass a broader range of behaviors and actions. "Violence" generally refers to the intentional use of physical force to cause harm, injury, or damage to another person (eg, physical assault, domestic violence, street fights, or acts of terrorism), whereas "mistreatment" is a more general term and refers to the abuse, harm, or control exerted over another person (such as nonconsensual medical procedures, verbal abuse, disrespect, discrimination and stigmatization, or neglect, to name a few examples). There may be cases where unprofessional personnel may commit mistreatment and violence against pregnant patients, but as obstetrics is dedicated to the health and well-being of pregnant and fetal patients, mistreatment of obstetric patients should never be an intended component of professional obstetric care. It is necessary to move beyond the term "obstetric violence" in discourse and acknowledge and address the structural dimensions of abusive reproductive practices. Similarly, we do not use the term "psychiatric violence" for appropriately used professional procedures in psychiatry, such as electroshock therapy, or use the term "neurosurgical violence" when drilling a burr hole. There is an ongoing need to raise awareness about the potential mistreatment of obstetric patients within the context of abuse against women in general. Using the term "mistreatment in healthcare" instead of the more limited term "obstetric violence" is more appropriate and applies to all specialties when there is unprofessional abuse and mistreatment, such as biased care, neglect, emotional abuse (verbal), or physical abuse, including performing procedures that are unnecessary, unindicated, or without informed patient consent. Healthcare providers must promote unbiased, respectful, and patient-centered professional care; provide an ethical framework for all healthcare personnel; and work toward systemic change to prevent any mistreatment or abuse in our specialty.

Mammalian target of rapamycin inhibitors: A new-possible approach for in-utero medication therapy.

The mammalian/mechanistic target of rapamycin (mTOR) is a protein kinase that plays a crucial role in regulating cellular growth, metabolism, and survival. Although there is no absolute contraindication for the use of mTOR inhibitors during pregnancy, the specific fetal effects remain unknown. Available data from the past 2 decades have examined the use of mTOR inhibitors during pregnancy in patients with solid organ transplantation, showing no clear link to fetal complications or structural abnormalities. Recently, a handful of case reports and series have described transplacental therapy of mTOR inhibitors to control symptomatic and complicated pathologies in the fetus. The effect of these agents includes a significant reduction in lesion size in the fetus and a reduced need for mechanical ventilation in neonates. In this context, we delve into the potential of mTOR inhibitors as in-utero therapy for fetal abnormalities, with a primary focus on lymphatic malformation (LM) and cardiac rhabdomyoma (CR). While preliminary reports underscore the efficacy of mTOR inhibitors for the treatment of fetal CR and fetal brain lesions associated with tuberous sclerosis complex, chylothorax, and LMs, additional investigation and clinical trials are essential to comprehensively assess the safety and efficacy of these medications.

Why do women choose home births.

In recent years, the US has seen a significant rise in the rate of planned home births, with a 60 % increase from 2016 to 2023, reaching a total of 46,918. This trend positions the US as the leading developed country in terms of home birth prevalence. The American College of Obstetricians and Gynecologists (ACOG) suggests stringent criteria for selecting candidates for home births, but these guidelines have not been adopted by home birth midwives leading to poor outcomes including increased rates of neonatal morbidity and mortality. This paper explores the motivations behind choosing home births in the US despite the known risks. Studies highlight factors such as the desire for a more natural birth experience, previous negative hospital experiences, and the influence of the COVID-19 pandemic on perceptions of hospital safety. We provide new insights into why women choose home births by incorporating insights from Nobel laureate Daniel Kahneman's theories on decision-making, suggesting that cognitive biases may significantly influence these decisions. Kahneman's work provides a framework for understanding how biases and heuristics can lead to the underestimation of risks and overemphasis on personal birth experiences. We also provide recommendations ("nudges according to Richard Thaler") to help ensure women have access to clear, balanced information about home births. The development of this publication was assisted by OpenAI's ChatGPT-4, which facilitated the synthesis of literature, interpretation of data, and manuscript drafting. This collaboration underscores the potential of integrating advanced computational tools in academic research, enhancing the efficiency and depth of our analyses.

Comprehensive appraisal of pregnancy and neonatal outcomes in singleton pregnancies conceived via in vitro fertilization in the USA (2016-2021).

OBJECTIVES: We set out to compare adverse pregnancy and neonatal outcomes in singleton gestations conceived via in vitro fertilization (IVF) to those conceived spontaneously. METHODS: Retrospective, population-based cohort using the CDC Natality Live Birth database (2016-2021). All singleton births were stratified into two groups: those conceived via IVF, and those conceived spontaneously. The incidence of several adverse pregnancy and neonatal outcomes was compared between the two groups using Pearson's chi-square test with Bonferroni adjustments. Multivariate logistic regression was used to adjust outcomes for potential confounders. RESULTS: Singleton live births conceived by IVF comprised 0.86 % of the cohort (179,987 of 20,930,668). Baseline characteristics varied significantly between the groups. After adjusting for confounding variables, pregnancies conceived via IVF were associated with an increased risk of several adverse pregnancy and neonatal outcomes compared to those conceived spontaneously. The maternal adverse outcomes with the highest risk in IVF pregnancies included maternal transfusion, unplanned hysterectomy, and maternal intensive care unit admission. Increased rates of hypertensive disorder of pregnancy, preterm birth (delivery <37 weeks of gestation), and cesarean delivery were also noted. The highest risk neonatal adverse outcomes associated with IVF included immediate and prolonged ventilation, neonatal seizures, and neonatal intensive care unit admissions, among others. CONCLUSIONS: Based on this large contemporary United States cohort, the risk of several adverse pregnancy and neonatal outcomes is increased in singleton pregnancies conceived via IVF compared to those conceived spontaneously. Obstetricians should be conscious of these associations while caring for and counseling pregnancies conceived via IVF.

The exciting potential for ChatGPT in obstetrics and gynecology.

Natural language processing-the branch of artificial intelligence concerned with the interaction between computers and human language-has advanced markedly in recent years with the introduction of sophisticated deep-learning models. Improved performance in natural language processing tasks, such as text and speech processing, have fueled impressive demonstrations of these models' capabilities. Perhaps no demonstration has been more impactful to date than the introduction of the publicly available online chatbot ChatGPT in November 2022 by OpenAI, which is based on a natural language processing model known as a Generative Pretrained Transformer. Through a series of questions posed by the authors about obstetrics and gynecology to ChatGPT as prompts, we evaluated the model's ability to handle clinical-related queries. Its answers demonstrated that in its current form, ChatGPT can be valuable for users who want preliminary information about virtually any topic in the field. Because its educational role is still being defined, we must recognize its limitations. Although answers were generally eloquent, informed, and lacked a significant degree of mistakes or misinformation, we also observed evidence of its weaknesses. A significant drawback is that the data on which the model has been trained are apparently not readily updated. The specific model that was assessed here, seems to not reliably (if at all) source data from after 2021. Users of ChatGPT who expect data to be more up to date need to be aware of this drawback. An inability to cite sources or to truly understand what the user is asking suggests that it has the capability to mislead. Responsible use of models like ChatGPT will be important for ensuring that they work to help but not harm users seeking information on obstetrics and gynecology.

The impact of birth settings on pregnancy outcomes in the United States.

In the United States, 98.3% of patients give birth in hospitals, 1.1% give birth at home, and 0.5% give birth in freestanding birth centers. This review investigated the impact of birth settings on birth outcomes in the United States. Presently, there are insufficient data to evaluate levels of maternal mortality and severe morbidity according to place of birth. Out-of-hospital births are associated with fewer interventions such as episiotomies, epidural anesthesia, operative deliveries, and cesarean deliveries. When compared with hospital births, there are increased rates of avoidable adverse perinatal outcomes in out-of-hospital births in the United States, both for those with and without risk factors. In one recent study, the neonatal mortality rates were significantly elevated for all planned home births: 13.66 per 10,000 live births (242/177,156; odds ratio, 4.19; 95% confidence interval, 3.62-4.84; P<.0001) vs 3.27 per 10,000 live births for in-hospital Certified Nurse-Midwife-attended births (745/2,280,044; odds ratio, 1). These differences increased further when patients were stratified by recognized risk factors such as breech presentation, multiple gestations, nulliparity, advanced maternal age, and postterm pregnancy. Causes of the increased perinatal morbidity and mortality include deliveries of patients with increased risks, absence of standardized criteria to exclude high-risk deliveries, and that most midwives attending out-of-hospital births in the United States do not meet the gold standard for midwifery regulation, the International Confederation of Midwives' Global Standards for Midwifery Education. As part of the informed consent process, pregnant patients interested in out-of-hospital births should be informed of its increased perinatal risks. Hospital births should be supported for all patients, especially those with increased risks.

Addressing challenges related to the professional practice of abortion post-Roe.

The landmark Roe vs Wade Supreme Court decision in 1973 established a constitutional right to abortion. In June 2022, the Dobbs vs Jackson Women's Health Organization Supreme Court decision brought an end to the established professional practice of abortion throughout the United States. Rights-based reductionism and zealotry threaten the professional practice of abortion. Rights-based reductionism is generally the view that moral or ethical issues can be reduced exclusively to matters of rights. In relation to abortion, there are 2 opposing forms of rights-based reductionism, namely fetal rights reductionism, which emphasizes the rights for the fetus while disregarding the rights and autonomy of the pregnant patient, and pregnant patient rights reductionism, which supports unlimited abortion without regards for the fetus. The 2 positions are irreconcilable. This article provides historical examples of the destructive nature of zealotry, which is characterized by extreme devotion to one's beliefs and an intolerant stance to opposing viewpoints, and of the importance of enlightenment to limit zealotry. This article then explores the professional responsibility model as a clinically ethically sound approach to overcome the clashing forms of rights-based reductionism and zealotry and to address the professional practice of abortion. The professional responsibility model refers to the ethical and professional obligations that obstetricians and other healthcare providers have toward pregnant patients, fetuses, and the society at large. It provides a more balanced and nuanced approach to the abortion debate, avoiding the pitfalls of reductionism and zealotry, and allows both the rights of the woman and the obligations to pregnant and fetal patients to be considered alongside broader ethical, medical, and societal implications. Constructive and respectful dialogue is crucial in addressing diverse perspectives and finding common ground. Embracing the professional responsibility model enables professionals to manage abortion responsibly, thereby prioritizing patients' interests and navigating between absolutist viewpoints to find balanced ethical solutions.

Professional virtue of civility and the responsibilities of medical educators and academic leaders.

Incivility among physicians, between physicians and learners, and between physicians and nurses or other healthcare professionals has become commonplace. If allowed to continue unchecked by academic leaders and medical educators, incivility can cause personal psychological injury and seriously damage organisational culture. As such, incivility is a potent threat to professionalism. This paper uniquely draws on the history of professional ethics in medicine to provide a historically based, philosophical account of the professional virtue of civility. We use a two-step method of ethical reasoning, namely ethical analysis informed by pertinent prior work, followed by identifying the implications of clearly articulated ethical concepts, to meet these goals. The professional virtue of civility and the related concept of professional etiquette was first described by the English physician-ethicist Thomas Percival (1740-1804). Based on a historically informed philosophical account, we propose that the professional virtue of civility has cognitive, affective, behavioural and social components based on a commitment to excellence in scientific and clinical reasoning. Its practice prevents a dysfunctional organisational culture of incivility and sustains a civility-based organisational culture of professionalism. Medical educators and academic leaders are in a pivotal and powerful position to role model, promote and inculcate the professional virtue of civility as essential to an organisational culture of professionalism. Academic leaders should hold medical educators accountable for discharge of this indispensable professional responsibility.

Covid and pregnancy in the United States - an update as of August 2022.

COVID-19 is caused by the 2019 novel coronavirus (2019-nCoV). The first cases of COVID-19 were identified in December 2019, and the first United States (US) case was identified on January 20th, 2020. Since then, COVID-19 has spread throughout the world and was declared a pandemic by the WHO on March 11, 2020. As of July 2022, about 90 million persons have been infected with COVID-19 in the US, and there have been over 1 million deaths There have been 224,587 pregnant patients infected with COVID-19, and 34,527 were hospitalized. Pregnancy increases the risk of severe disease associated with COVID-19 and vaccinated patients are significantly less likely to develop severe disease. Adverse pregnancy and neonatal outcomes are more common among women infected with SARS-CoV-2 during pregnancy, especially among those with severe disease, and vaccination also protects the newborn infant. The intrauterine transmission of SARS-CoV-2 appears to be rare. COVID-19 vaccinations and booster shots in pregnancy are safe. In addition, the available data suggest that vaccination during pregnancy is associated with the transmission of SARS-CoV-2 antibodies to the fetus. The vaccination of lactating women is associated with high levels of SARS-CoV-2 antibodies in the breast milk. It is important that with future pandemics the concept of vaccine recommendations in pregnancy should be made early on to prevent maternal, fetal, and neonatal morbidity and mortality. Physicians and other healthcare professionals should strongly recommend COVID-19 vaccination to patients who are pregnant, planning to become pregnant, and to those who are breastfeeding.

Maternal race/ethnicity impacts the success rates of external cephalic version (ECV) in the United States.

OBJECTIVES: Racial and ethnic disparities in obstetrics are prevalent in the United States (US). We aimed to assess whether the success rate of external cephalic version (ECV) is affected by maternal race/ethnicity. METHODS: We conducted a retrospective analysis based on the CDC Natality Live Birth database for 2016-2018. We compared the success rates of ECV across US pregnant women of different racial/ethnic groups (non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic Asians, and Hispanics) using the Pearson chi-square test and used multivariate logistic regression to control for confounding variables. Statistical signiciance was determined as p<0.05 and results were displayed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). RESULTS: Of the 11,150,527 births, 26,255 women underwent an ECV and met inclusion criteria. The overall ECV success rate was 52.75% (13,850 women). Non-Hispanic Blacks had the highest ECV success rate (64.52%), followed by Hispanics (59.21%) and non-Hispanic Asians (55.51%). These rates were significantly higher than those of non-Hispanic Whites (49.27%, p<0.001). Non-Hispanic Blacks were associated with the highest success rate compared to non-Hispanic Whites (adjusted OR 1.95, 95% CI 1.77-2.15). CONCLUSIONS: The success rate of ECV varies among different maternal racial/ethnic groups. Non-Hispanic White women have the lowest ECV success rate, while non-Hispanic Black women have the highest ECV success rate.

Risk factors associated with third- and fourth-degree perineal lacerations in singleton vaginal deliveries: a comprehensive United States population analysis 2016-2020.

OBJECTIVES: Perineal lacerations are a common complication of vaginal birth, affecting approximately 85 % of patients. Third-and fourth-degree perineal lacerations (3/4PL) remain a significant cause of physical and emotional distress. We aimed to perform an extensive assessment of potential risk factors for 3/4PL based on a comprehensive and current US population database. METHODS: Retrospective population-based cohort analysis based on the US Centers for Disease Control and Prevention Natality Live Birth online database between 2016-2020. Baseline characteristics were compared between women with 3/4PL and without 3/4PL by using Pearson's Chi-squared test with statistical significance set at p<0.05. Bonferroni correction was used to account for multiple comparisons. Multivariable logistic regression was performed to evaluate the association between a variety of potential risk factors and the risk of 3/4P. RESULTS: Asians/Pacific Islanders had the highest risk of 3/4PL (2.6 %, aOR 1.74). Gestational hypertension and preeclampsia were associated with increased risk of 3/4PL (aOR 1.28 and 1.34, respectively), as were both pre-gestational and gestational diabetes (aOR 1.28 and 1.46, respectively). Chorioamnionitis was associated almost double the risk (aOR 1.86). Birth weight was a major risk factor (aOR 7.42 for greater than 4,000 g), as was nulliparity (aOR 9.89). CONCLUSIONS: We identified several maternal, fetal, and pregnancy conditions that are associated with an increased risk for 3/4PL. As expected, nulliparity and increased birth weight were associated with the highest risk. Moreover, pregestational and gestational diabetes, hypertensive disorders of pregnancy, Asian/Pacific Islander race, and chorioamnionitis were identified as novel risk factors.

New Jersey maternal mortality dashboard: an interactive social-determinants-of-health tool.

OBJECTIVES: The United States maternal mortality (MM) rate is the highest amid developed/industrialized nations, and New Jersey's rate is among the highest. Healthcare professionals, public health officials, and policy makers are working to understand drivers of MM. An interactive data visualization tool for MM and health-related information (New Jersey Maternal Mortality Dashboard [NJMMD]) was recently developed. METHODS: NJMMD is an open-source application that uses data from publicly available state/federal government sources to provide a cross-sectional, high-level depiction of potential relationships between MM and demographic, social, and public health factors. RESULTS: MM rates or ratios (maternal deaths/1,000 women aged 15-49 years or 100,000 live births, respectively) are available by year (2005-2017), age (5-year [15-49] periods), and race/ethnicity (non-Hispanic White, Black, or Asian; Hispanic; or other), and by contextual social determinants of health (percent insured; percent covered by Medicaid; difference in nulliparous, term, singleton, vertex Cesarian birth rate from New Jersey goal; number of obstetrician/gynecologists or midwives per capita; and poverty rate). Bar graphs also can be produced with these variables. CONCLUSIONS: NJMMD is the first publicly available, interactive, state-focused MM tool that takes into account the intersection of social and demographic determinants of health, which play important roles in health outcomes. Trends and patterns in variables associated with MM and health can be identified for New Jersey and each of its 11 counties, and inform areas of focus for further analysis. Outputs may enable researchers, policy makers, and others to develop appropriate interventions and be better positioned to set benchmarks, allocate resources, and evaluate outcomes.

Prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States: a systematic review and meta-analysis.

This systematic review and meta-analysis assessed the risk of inadequate prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States. PubMed/MedLine, Embase, ClinicalTrials.gov and Web of Science were searched from inception up to March 30th, 2022. Studies were included if they reported the risk of inadequate prenatal care and/or pregnancy outcomes among incarcerated pregnant individuals in the United States jails or prisons. Adequacy of prenatal care was quantified by Kessner index. The random-effects model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals (CIs) using RevMan software. Nine studies were included in the final review. A total of 11,534 pregnant individuals, of whom 2,544 were incarcerated while pregnant, and 8,990 who were matched non-incarcerated pregnant individuals serving as control group, were utilized. Compared to non-incarcerated pregnancies, incarcerated pregnant individuals were at higher risk of inadequate prenatal care (OR 2.99 [95% CI: 1.60, 5.61], p<0.001) and were more likely to have newborns with low birthweight (OR 1.66 [95% CI: 1.19, 2.32], p=0.003). There was no significant difference between incarcerated and matched control pregnancies in the rates of preterm birth and stillbirth. The findings of the current systematic review and meta-analysis suggest that incarcerated pregnant individuals have an increased risk of inadequate prenatal care. Considering the limited number of current studies, further research is indicated to both assess whether the risk of inadequate prenatal care has negative impact on prenatal outcomes for this population and to determine the steps that can be taken to enhance prenatal care for all pregnant individuals incarcerated in the United States prisons.

Hidden in plain sight in the delivery room - the Apgar score is biased.

OBJECTIVES: The objective of this study was to compare the maximum 5-min Apgar score of 10 among different U.S. races and Hispanic ethnicity. METHODS: Retrospective population-based cohort study from the National Center for Health Statistics (NCHS), and Division of Vital Statistics natality online database. We included only deliveries where the race and Hispanic ethnicity of the father and mother were listed as either Black, White, Chinese, or Asian Indian and as Hispanic or Latino origin or other. Proportions of 5-Minute Apgar scores of 10 were compared among different races and Hispanic ethnicity for six groups each for mother and father: Non-Hispanic or Latino White, Hispanic or Latino White, Non-Hispanic or Latino Black, Hispanic or Latino Black, Chinese, and Asian Indian. RESULTS: The study population consists of 9,710,066 mothers and 8,138,475 fathers from the US natality birth data 2016-2019. Black newborns had a less than 50% chance of having a 5-min Apgar score of 10 when compared to white newborns (OR 0.47 for Black mother and Black father; p<0.001). White babies (non-Hispanic and Hispanic) had the highest proportion of Apgar scores of 10 across all races and ethnicities. CONCLUSIONS: The Apgar score introduces a bias by systematically lowering the score in people of color. Embedding skin color scoring into basic data and decisions of health care propagates race-based medicine. By removing the skin color portion of the Apgar score and with it's racial and ethnic bias, we will provide more accuracy and equity when evaluating newborn babies worldwide.

"We All Want to Be Able to Tell You Something Hopeful": Clinicians' Experiences Providing Maternal-Fetal Surgery Counseling.

INTRODUCTION: Prenatal counseling about maternal-fetal surgery can be traumatic and confusing for pregnant people. It can also be technically and emotionally complex for clinicians. As maternal-fetal surgery rapidly advances and becomes more common, more evidence is needed to inform counseling practices. The objective of this study was to develop a deeper understanding of the methods clinicians currently use to train for and provide counseling, as well as their needs and recommendations for future education and training. METHODS: We used interpretive description methods and interviewed interprofessional clinicians who regularly counsel pregnant people about maternal-fetal surgery. RESULTS: We conducted 20 interviews with participants from 17 different sites who were maternal-fetal medicine specialists (30%), pediatric surgeons (30%), nurses (15%), social workers (10%), a genetic counselor (5%), a neonatologist (5%), and a pediatric subspecialist (5%). Most were female (70%), non-Hispanic white (90%), and practiced in the Midwest (50%). We identified four overarching themes: (1) contextualizing maternal-fetal surgery counseling; (2) establishing shared understanding; (3) supporting decision-making; and (4) training for maternal-fetal surgery counseling. Within these themes, we identified key practice differences among professions, specialties, institutions, and regions. CONCLUSION: Participants are committed to practicing informative and supportive counseling to empower pregnant people to make autonomous decisions about maternal-fetal surgery. Nevertheless, our findings indicate a dearth of evidence-based communication practices and guidance. Participants identified significant systemic limitations affecting pregnant people's decision-making options related to maternal-fetal surgery.

The far-reaching impact of abortion bans: reproductive care and beyond.

On 24 June 2022, the US Supreme Court overturned Roe v. Wade, a 49-year-old precedent that provided federal constitutional protection for abortions up to the point of foetal viability, returning jurisdiction to the individual states. Restrictions that came into effect automatically in several states, and are anticipated in others, will severely limit access to abortions in approximately half of the US. Even though every state allows for exceptions to the abortion bans, in some instances these exceptions can be used to preserve the health of a pregnant patient, while in other instances, only to preserve their life. The vague and confusing nature of the abortion ban exceptions threatens to compromise the standard of care for patients with pregnancy complications that are distinct from abortions, such as nonviable pregnancies, miscarriages, and ectopic pregnancies. Additionally, we envision challenges for the treatment of women with certain autoimmune conditions, pregnant cancer patients, and patients contemplating preimplantation genetic diagnosis as part of assisted reproductive technologies. The abortion ban exceptions will impact and interfere with the medical care of pregnant and non-pregnant patient populations alike and are poised to create a medical and public health crisis unlike any other one from the recent past.

Sociodemographic Factors Associated With Gonorrhea and Chlamydia Infection in Pregnancy.

BACKGROUND: We explored the impact of maternal sociodemographic parameters on the prevalence of chlamydial and gonorrheal infection in pregnancy in a large United States population of live births. METHODS: Retrospective analysis of the Centers for Disease Control and Prevention Natality Live Birth database (2016-2019). We compared pregnancies complicated by maternal infection with either gonorrhea or chlamydia to those without gonorrheal or chlamydial infection, separately. Both analyses included assessment of multiple maternal sociodemographic factors, which were compared between the 2 groups. Multivariable logistic regression was performed to evaluate the association of these factors with gonorrheal or chlamydial infection in pregnancy. RESULTS: Of the 15,341,868 included live births, 45,639 (0.30%) were from patients who had gonorrheal infection, and 282,065 (1.84%) were from patients who had chlamydial infection during pregnancy. Concurrent infection with chlamydia and gonorrhea was associated with the highest risk of gonorrhea and chalmydia in pregnancy (adjusted odds ratio, 26.28; 95% confidence interval, 25.74-26.83, and adjusted odds ratio, 26.03; 95% confidence interval, 25.50-26.58, respectively). Young maternal age, low educational attainment, non-Hispanic Black race/ethnicity, concurrent infection with syphilis, and tobacco use were also associated with a substantial increase in the risk of gonorrheal and chlamydial infection in pregnancy. CONCLUSIONS: Several sociodemographic factors including young maternal age, low educational attainment, Medicaid insurance, and non-Hispanic Black race/ethnicity, are associated with a marked increase in the risk for gonorrheal and chlamydial infection in current US pregnancies. These data may be used to better screen, educate, and treat pregnancies of vulnerable populations at risk for such infections.

Reversing physician hesitancy to recommend COVID-19 vaccination for pregnant patients.

Physician hesitancy is said to occur when physicians do not recommend COVID-19 vaccination, and it is a contributing factor for the low vaccination rate for COVID-19 in pregnant women. Physician hesitancy has become a major, unaddressed problem with regard to the quality and safety of obstetrical care. We identify 3 root causes of physician hesitancy and describe how professional ethics in obstetrics should guide in reversing these root causes. They are clinical misapplications of key components of professionally responsible obstetrical practice: therapeutic nihilism, shared decision-making, and respect for patient autonomy. Therapeutic nihilism directs the obstetrician to avoid any clinical interventions during pregnancy to prevent teratogenic effects that might be unknown. Therapeutic nihilism is misapplied when there is a documented net clinical benefit with no evidence of clinical harm. Shared decision directs the obstetrician to only offer but not recommend clinical management. Shared decision-making plays a major role when there is uncertainty in clinical judgment but is misapplied when it becomes a universal model. It does not apply when there is a net clinical benefit. When there is a net clinical benefit, clinical management should be recommended, not simply offered. The ethical principle of respect for patient autonomy plays an indispensable role in decision-making with patients. It is misapplied when it is assumed that respect for autonomy requires physicians not to make recommendations and to defer to and implement patients' decisions without exception. There is evidence that the obstetrician's recommendations about the management of pregnancy are the most important factor in a pregnant woman's decision-making. Simply deferring to the patient's decisions makes for misapplied respect for patient autonomy. Obstetricians must end physician hesitancy about COVID-19 vaccination of pregnant women by reversing these 3 root causes of physician hesitancy. Reversing the root causes of physician hesitancy is an urgent matter of patient safety. The longer physician hesitancy continues and the longer the low vaccine acceptance rate of pregnant women lasts, preventable serious diseases, deaths of pregnant women, intensive care unit admissions, stillbirths, and other maternal and fetal complications of unvaccinated women will continue to occur. Physician hesitancy should not be permitted to influence the response to future pandemics.

Undue burdens created by the Texas Abortion Law for vulnerable pregnant women.

The new Texas abortion law requires the physician to determine whether a fetal heartbeat is present and prohibits abortion after a heartbeat has been documented. An exception is allowed when a "medical emergency necessitated the abortion." These and other provisions of the statute are to be enforced through "civil actions" brought by private citizens. This article identifies 3 populations of vulnerable women who will experience undue burdens created by the Texas abortion law. We begin with an account of the concept of undue burden in the jurisprudence of abortion, as expressed in the 1992 US Supreme Court case, Planned Parenthood v. Casey of Southeastern Pennsylvania. We then provide an evidence-based account of the predictable, undue burdens for 3 populations of vulnerable women: pregnant women with decreased freedom of movement; pregnant minors; and pregnant women with major mental disorders and cognitive disabilities. The Texas law creates an undue burden on these 3 populations of vulnerable women by reducing or even eliminating access to abortion services outside of Texas. The Texas law also creates an undue burden by preventably increasing the risks of morbidity, including loss of fertility, and mortality for these 3 populations of vulnerable women. For these women, it is indisputable that the Texas law will create undue burdens and is therefore not compatible with the jurisprudence of abortion as set forth in Planned Parenthood v. Casey because a "significant number of women will likely be prevented from obtaining an abortion." Federal courts should therefore strike down this law.

Neonatal outcomes of births in freestanding birth centers and hospitals in the United States, 2016-2019.

BACKGROUND: Births in freestanding birth centers have more than doubled between 2007 and 2019. Although birthing centers, which are defined by the American College of Obstetricians and Gynecologists as ". . . freestanding facilities that are not hospitals," are being promoted as offering women fewer interventions than hospitals, there are limited recent data available on neonatal outcomes in these settings. OBJECTIVE: To compare several important measures of neonatal safety between 2 United States birth settings and birth attendants: deliveries in freestanding birth centers and hospital deliveries by midwives and physicians. STUDY DESIGN: This is a retrospective cohort study using the United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, and Division of Vital Statistics natality online database for the years 2016 to 2019. All term, singleton, low-risk births were eligible for inclusion. The study outcomes were several neonatal outcomes including neonatal death, neonatal seizures, 5-minute Apgar scores of <4 and <7, and neonatal death in nulliparous and in multiparous women. Outcomes were compared between the following 3 groups: births in freestanding birth centers, in-hospital births by a physician, and in-hospital births by a midwife. The prevalence of each neonatal outcome among the different groups was compared using Pearson chi-squared test, with the in-hospital midwife births being the reference group. Multivariate logistic regression models were performed to account for several potential confounding factors such as maternal prepregnancy body mass index, maternal weight gain, parity, gestational weeks, and neonatal birthweight and calculated as adjusted odds ratio. RESULTS: The study population consisted of 9,894,978 births; 8,689,467 births (87.82%) were in-hospital births by MDs and DOs, 1,131,398 (11.43%) were in-hospital births by midwives, and 74,113 (0.75%) were births in freestanding birth centers. Freestanding birth center deliveries were less likely to be to non-Hispanic Black or Hispanic, less likely to women with public insurance, less likely to be women with their first pregnancy, and more likely to be women with advanced education and to have pregnancies at ≥40 weeks' gestation. Births in freestanding birth center had a 4-fold increase in neonatal deaths (3.64 vs 0.95 per 10,000 births: adjusted odds ratio, 4.00; 95% confidence interval, 2.62-6.1), a more than 7-fold increase in neonatal deaths for nulliparous patients (6.8 vs 0.92 per 10,000 births: adjusted odds ratio, 7.7; 95% confidence interval, 4.42-13.76), a more than 2-fold increase in neonatal seizures (3.91 vs 1.94 per 10,000 births: adjusted odds ratio, 2.19; 95% confidence interval, 1.48-3.22), and a more than 7-fold increase of a 5-minute Apgar score of <4 (194.84 vs 28.5 per 10,000 births: adjusted odds ratio, 7.46; 95% confidence interval, 7-7.95). Compared with hospital midwife deliveries, hospital physician deliveries had significantly higher adverse neonatal outcomes (P<0.001). CONCLUSION: Births in United States freestanding birth centers are associated with an increased risk of adverse neonatal outcomes such as neonatal deaths, seizures, and low 5-minute Apgar scores. Therefore, when counseling women about the location of birth, it should be conveyed that births in freestanding birth centers are not among the safest birth settings for neonates compared with hospital births attended by either midwives or physicians.