Across 27 studies and 13,724 women who froze their eggs, about 11 in 100 ever came back for them — and fewer than 3 in 10 of those had a baby. Everything else about egg freezing follows from that one number.

On a Sunday livestream, a member of Congress pointed a fertility injection at her own belly and told her followers not to be weird about it. “don’t be weird about this,” she said.

They were weird about it.

Within two days the conversation had moved from her eggs to her breakup, her politics, and whether she was selling other women a fantasy about having it all.

Her private life is not my business.

What she was told before the needle went in is, and so is what the millions of women watching now believe about egg freezing.

That is not politics.

It is a medical question with numbers attached, and the numbers are not the ones in the advertising.

Begin with what the procedure is.

For ten to twelve days a woman injects hormones so that many eggs mature at once instead of the single egg her body would release on its own.

The eggs are collected under sedation, and the mature ones are flash-frozen in liquid nitrogen and stored.

That is all of it.

An egg is not an embryo, and an embryo is not a baby. About eight in ten eggs survive thawing. Of those, some fertilize. Of those, some become usable embryos. Of those, some implant.

Every step subtracts.

Now the numbers that rarely appear on a clinic homepage.

The largest review to date pooled 27 studies and 13,724 women who froze eggs to delay childbearing, with a median follow-up of seven years. Just under 11 in every 100 came back to thaw them. Of the few who returned, 29 in 100 had a baby. A long-running New York cohort followed women who froze between 2005 and 2009 for ten to fifteen years, long enough for a final answer: 38 in 100 used their eggs and 59 in 100 never did. That is the highest return rate published anywhere, and it is still fewer than four women in ten.

When women do come back, the eggs work better than the pessimists claim.

Among 543 women who thawed at that center, 39 in 100 ended up with a baby, and more than half succeeded if they had been under 38 at freezing or thawed at least 20 mature eggs. A widely used counseling model puts 20 mature eggs frozen at 34 at roughly a 90 percent chance of a live birth, about 75 percent at 37, and about 37 percent at 42. That model came from laboratory data rather than from women who returned, as its authors said plainly, and real outcomes run below modeled ones. The shape still holds, and it is the point: age at freezing is the whole ballgame.

The strongest argument against my position deserves a hearing: egg freezing is undersold, not oversold.

In a 2025 survey of 260 women who had frozen eggs, the typical woman guessed her chance of a baby at 50 percent when the model put it at 75. Regret runs opposite to what critics assume — in a study of 173 women, 9 percent regretted freezing and 51 percent regretted not doing it. Those findings are real. But the comparison number is a model, not a birth, and regret was measured six months out, years before anyone learns whether the eggs work. Fear of missing the window is easy to capture early. Disappointment arrives a decade later, quietly, in a different clinic.

Then there is what freezing does not preserve.

Freezing an egg at 35 does not freeze the woman around it. If she returns at 44 she is pregnant at 44, with the higher rates of high blood pressure, diabetes in pregnancy, cesarean delivery and stillbirth that come with pregnancy after 35 and climb steeply after 40.

And there is money, which deserves its own paragraph because clinics almost never put it in one.

The figures below come from clinic and market price lists rather than peer-reviewed cost studies, and they vary by region. Up front, the procedure itself — monitoring, retrieval, freezing — runs about $8,000 to $15,000 for one cycle. The hormone injections are usually billed separately by the pharmacy and add roughly $3,000 to $7,000. All in, one cycle lands near $12,000 to $20,000, and most women need two, so the realistic entry price is about $24,000 to $36,000. Then the meter starts. Storage runs about $500 to $1,000 a year at most clinics, higher in the big cities and lower at off-site cryobanks: call it $40 to $85 every month, roughly a phone bill, for as long as the eggs sit there. Ten years of that is another $5,000 to $10,000. And the thaw itself — warming, fertilization, embryo culture, genetic testing, transfer — is a separate bill years later, closer to a full round of in vitro fertilization than to a retrieval. With an 11 percent return rate, most women pay the entry price and the monthly fee for a decade and use none of it.

This is where the ethics live, and they are not complicated.

The 2024 ethics opinion of the American Society for Reproductive Medicine says planned oocyte cryopreservation is permissible, that patients should be told the benefits are uncertain, and that providers should disclose their own center’s freeze-thaw and live-birth results — or admit they have none.

That is exactly right and almost nowhere honored. Count the clinic pages that open with “peace of mind” and “take control of your future,” then count the ones that open with their own thaw-to-birth rate. The distance between them is the consent failure.

I part company here with the profession’s favorite hiding place, which is choice.

Handing a woman a menu is not counseling her.

Three numbers belong in the first conversation, before any deposit: her chance of a live birth at her age with the number of eggs this center actually retrieves, her chance of never using them at all, and the full cost including the thaw and transfer years later. A clinician who leaves those out has not respected her autonomy. He has handed her a brochure and called it consent.

Behind the small abandonment sits a larger one.

When an employer pays for egg freezing but not for childcare, paid leave, or a career that survives having a child at 30, a structural problem has been relocated into a woman’s ovaries.

That is cheaper for the employer. It is not cheaper for her.

My position is this.

Egg freezing is a real technology with a modest, steeply age-dependent yield, and it is not insurance.

It belongs in a conversation in the early thirties rather than the late thirties, with enough eggs banked to matter, and with the return rate in the first sentence rather than the fifth.

I would tell any woman considering it what I would want told to my own granddaughter: frozen eggs are a chance, not a plan; the chance at 32 is far better than the chance at 38; and the most valuable thing a clinic can give her is not the freezing but the truth about her own numbers, early enough that she still has choices. Whether she freezes her eggs is nobody’s verdict on her ambition. Whether she was told the truth first is a professional obligation, and we are failing it.

If you know someone deciding this right now, send her the return rate before she sends anyone a deposit. ObGyn Intelligence is free because the evidence should travel. A paid subscription keeps it independent.

References

1. Kirubarajan A, Patel P, Thangavelu N, Salim S, Sadeghi Y, Yeretsian T, et al. Return rates and pregnancy outcomes after oocyte preservation for planned fertility delay: a systematic review and meta-analysis. Fertil Steril. 2024;122(5):902-17. doi:10.1016/j.fertnstert.2024.06.025

2. Blakemore JK, Grifo JA, DeVore SM, Hodes-Wertz B, Berkeley AS. Planned oocyte cryopreservation—10-15-year follow-up: return rates and cycle outcomes. Fertil Steril. 2021;115(6):1511-20. doi:10.1016/j.fertnstert.2021.01.011

3. Cascante SD, Blakemore JK, DeVore S, Hodes-Wertz B, Fino ME, Berkeley AS, et al. Fifteen years of autologous oocyte thaw outcomes from a large university-based fertility center. Fertil Steril. 2022;118(1):158-66.

4. Goldman RH, Racowsky C, Farland LV, Munné S, Ribustello L, Fox JH. Predicting the likelihood of live birth for elective oocyte cryopreservation: a counseling tool for physicians and patients. Hum Reprod. 2017;32(4):853-9. doi:10.1093/humrep/dex008

5. Friedman M, Jaffe N, Tairy D, Torem M, Raziel A, Finkelstein M, et al. Do women accurately predict their odds of having a child following planned oocyte cryopreservation? Reprod Fertil. 2025. doi:10.1530/RAF-24-0118

6. Jaswa EG, Pasch LA, McGough A, Wong R, Corley J, Cedars MI, et al. Decision regret among women considering planned oocyte cryopreservation: a prospective cohort study. J Assist Reprod Genet. 2023;40(6):1281-90. doi:10.1007/s10815-023-02789-w

7. Ethics Committee of the American Society for Reproductive Medicine. Planned oocyte cryopreservation to preserve future reproductive potential: an Ethics Committee opinion. Fertil Steril. 2024;121(4):604-12. doi:10.1016/j.fertnstert.2023.12.030

8. American College of Obstetricians and Gynecologists. Pregnancy at age 35 years or older. Obstetric Care Consensus No. 11. Obstet Gynecol. 2022;140(2):348-66. doi:10.1097/AOG.0000000000004873

9. Karni A. With big choices ahead, Ocasio-Cortez navigates new territory. The New York Times. 2026 Aug 12.

Note on costs: the price ranges in the text come from clinic and market price lists, not from peer-reviewed cost analyses, and vary widely by region.

It is easy to warn people not to tell an artificial intelligence system too much about themselves.

• Do not enter your medical history.

• Do not describe your symptoms.

• Do not disclose your medications, pregnancy, mental health, or sexual history.

• Do not trust a chatbot with information that should remain between you and your doctor.

That advice sounds responsible.

It also assumes that you have a doctor.

For much of the world, that assumption is false.

In 2023, approximately 4.6 billion people were not fully covered by essential health services. In 2022, 2.1 billion experienced financial hardship because of health-care costs. The World Health Organization now projects a global shortage of approximately 11 million health workers by 2030, concentrated mainly in low- and lower-middle-income countries. These figures do not mean that every one of those people has literally never encountered a physician. They mean that dependable, timely, affordable access to needed care remains unavailable to more than half of humanity.

For these people, the relevant comparison is often not:

AI versus a trusted personal physician.

It is:

AI versus no appointment.
AI versus no transportation.
AI versus a clinic that is closed.
AI versus a consultation the patient cannot afford.
AI versus nobody who speaks the patient’s language.
AI versus searching alone at two o’clock in the morning.

Before we accuse people of “oversharing” with AI, we should ask a more uncomfortable question:

Who else were they supposed to ask?

What People Are Actually Asking AI

A 2026 study analyzed 617,827 health-related conversations with Microsoft Copilot from users around the world.

Approximately two in five conversations involved general health information and education. Nearly one in five involved personal symptoms or discussion of a specific medical condition. Additional conversations concerned emotional well-being, health insurance, medical paperwork, and navigating health-care systems.

Personal health questions increased during the evening and nighttime, precisely when conventional services were least available. Questions concerning emotional well-being increased especially sharply at night. Many people were also asking on behalf of children, partners, parents, or other people for whom they were providing care.

The accompanying Nature commentary reached the obvious conclusion: people are using conversational AI to fill gaps in access to health information and health-care systems.

This is not merely a story about technological enthusiasm.

It is a map of unmet need.

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The Privacy Debate Is Being Conducted From a Position of Privilege

A person with insurance, a primary physician, specialist access, an after-hours telephone service, reliable transportation, and a nearby emergency department can reasonably decide that the privacy risks of a chatbot are unnecessary.

That person has alternatives.

A woman in a remote community who has developed bleeding during pregnancy may not.

A patient who cannot afford another consultation may not.

A caregiver trying to understand an elderly parent’s new medication at midnight may not.

A person with a stigmatized condition who fears judgment or legal consequences may not.

A patient who waited six months for an appointment and was given seven minutes with a clinician may technically have “access,” but may still have no meaningful opportunity to ask questions.

Privacy matters. Confidentiality matters. Data security matters.

But privacy cannot be discussed as though it were the only ethical value.

People also have interests in obtaining information, understanding symptoms, recognizing danger, navigating a fragmented system, and making decisions before professional help becomes available. When these interests conflict, the answer cannot simply be to tell people with no realistic alternative to remain uninformed.

That is not protection.

It is abandonment expressed in the language of safety.

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When I joined my institution 25 years ago, misoprostol (”Cytotec”) was the default for labor induction.

For those unfamiliar, misoprostol is a synthetic prostaglandin E1 analog - a medication that causes the cervix to soften and the uterus to contract.

It’s FDA-approved for preventing gastric ulcers in patients taking NSAIDs like ibuprofen. It’s not FDA-approved for labor induction, cervical ripening, or any obstetric use whatsoever, yet it became one of the most commonly used drugs in labor and delivery.

Twenty-five micrograms (sometimes 50) vaginally every four hours. Simple. Efficient. No IV pump to program, no continuous rate adjustments, no nurse tied to the bedside watching an oxytocin drip.

Just drop the tablet in the vagina, document it, and come back in four hours.

Just drop the tablet in the vagina, document it, and come back in four hours.

Then I looked at our cesarean section logs. Tachysystole in 34% of inductions PubMed. Nonreassuring fetal heart tracings requiring urgent delivery. Emergency sections at 2 AM for Category 2 and 3 tracings that developed after the second or third dose of misoprostol.

We stopped using misoprostol.

Our cesarean rate for induction dropped.

Our emergency cesarean rate dropped more. Our NICU admission rate for term babies dropped too.

Our neonatologist even complained that he was losing money because admissions had dropped.

And we even published the data in the American Journal of Obstetrics and Gynecology (AJOG) to prove it.

Here’s why that happened.

The Safety Profile Nobody Discusses

When you compare vaginal misoprostol to other induction methods, the incidents of uterine hyperstimulation and tachysystole are significantly higher with misoprostol PubMed. Not marginally higher. Significantly higher.

The numbers: Tachysystole occurs in 24.3% of misoprostol inductions Springer. That’s nearly one in four. In one randomized trial comparing misoprostol to oxytocin, tachysystole occurred in 34.4% of the misoprostol group versus 13.8% in the oxytocin group PubMed.

Think about that. When you choose misoprostol, you’re tripling the risk of tachysystole.

The Number: In studies comparing misoprostol directly to Foley balloon catheters, uterine hyperstimulation was more common with misoprostol, though vaginal delivery rates were higher PubMed Central.

We’re trading safety for speed.

Why Do We Keep Using It?

Because it’s convenient.

From an economic standpoint, misoprostol is inexpensive compared with oxytocin and prostaglandin E2 preparations ScienceDirect.

But there’s another reason nobody says out loud: staffing.

Oxytocin requires continuous monitoring. A nurse at the bedside or nearby, watching the tracing, adjusting the rate every 30 minutes based on contraction pattern and fetal heart rate response. It requires attention. It requires personnel.

Misoprostol? Give it every four hours. The nurse can take care of three other patients. An oxytocin infusion can run unsupervised for many hours without a member of staff checking on its rate or effect on uterine contractions PubMed Central. That’s what makes oxytocin dangerous in understaffed settings.

But misoprostol avoids that risk by creating a different one: misoprostol needs to be regularly administered by a trained member of staff, a factor that forces some kind of regular clinical assessment ScienceDirect.

Regular doesn’t mean continuous. And continuous is what you need when 1 in 3 patients will develop tachysystole.

What Happens When You Stop Using Misoprostol

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Most physicians do not learn about malpractice from medical school.

We learn about it when a colleague is sued.

When a case appears in the news.

When a hospital risk-management committee reviews a bad outcome.

Or, worst of all, when the certified letter arrives with our own name on it.

That is too late.

I have now assembled more than 30 cases for a new series I am calling The MedMal Room.

Check the recent ones HERE.

They come from obstetrics, gynecology, fertility treatment, breast care, gynecologic oncology, surgery, postpartum care, and even conditions that are not technically “ObGyn” at all.

The purpose is not to frighten physicians.

It is not to teach defensive medicine.

And it is certainly not to imply that every bad outcome represents malpractice.

The purpose is much more useful:

to understand how good clinicians get into trouble, where preventable harm actually begins, and what we can change before the next patient is injured.

Malpractice Rarely Begins Where the Lawsuit Begins

A baby develops cerebral palsy.

A woman hemorrhages.

A postoperative patient becomes septic.

A breast cancer diagnosis is delayed.

An abnormal Pap test is never followed.

A suspicious mole seen during a gynecologic examination is referred to dermatology, but the patient never gets there.

An IVF laboratory transfers the wrong embryo.

These cases appear completely different.

But when you study them closely, the same patterns keep appearing.

The problem was recognized, but nobody acted.

The test was ordered, but nobody followed the result.

The referral was placed, but nobody knew whether the patient went.

A reassuring test result ended clinical thinking too early.

Everyone assumed someone else owned the next step.

The patient signed a consent form but never really understood the decision.

The physician knew something was wrong but failed to escalate.

Or the care was entirely appropriate, yet hindsight later made the bad outcome look preventable.

These are not just legal problems.

They are clinical reasoning problems, communication problems, systems problems, and ethical problems.

Check the recent ones HERE.

Some of the Cases Will Be Uncomfortable

One article asks:

Is a 30-minute emergency cesarean really a standard of care, or did a quality benchmark become a medicolegal rule?

Another asks:

Would an expert interpret the same fetal heart tracing differently if the expert did not know the baby developed cerebral palsy?

Another examines a woman with severe hypertension whose dangerous blood pressures were documented repeatedly.

Everyone knew.

Nobody treated them quickly enough.

Then there is the patient with a palpable breast lump and a “normal” mammogram.

The woman with repeated postmenopausal bleeding whose first reassuring evaluation became permanent reassurance.

The patient whose pelvic CT showed normal ovaries but incidentally found another potentially malignant lesion that nobody followed.

And one of my favorites because it captures the entire series:

A gynecologist sees a suspicious mole and refers the patient to dermatology.

She never goes.

Later she develops advanced melanoma.

Was the gynecologist’s responsibility finished when the referral was entered?

That is not really a dermatology question.

It is a question of professional responsibility.

Check the recent ones HERE.

Bad Outcome Does Not Equal Malpractice

This distinction will run through the entire series:

Bad outcome ≠ preventable harm ≠ medical error ≠ negligence.

Good medical care can end badly.

Bad medical care can sometimes end well.

A known complication can occur without negligence.

And a medical error can occur without causing injury.

If we collapse all of these into the word “malpractice,” we learn almost nothing.

The MedMal Room will separate them.

For every case, I want to ask:

What actually happened?

What should have happened?

What information was available at the time?

Was the outcome reasonably foreseeable?

Was there an error?

Was it preventable?

Did the system fail?

Did communication fail?

And most importantly:

What can the rest of us do differently tomorrow?

This Is Preventive Ethics

I have written for years about preventive ethics: the idea that professional responsibility should begin before the crisis.

The best time to explain an emergency cesarean is not always during the emergency.

The best time to teach postpartum warning signs is not after the patient develops severe symptoms at home.

The best time to establish an escalation protocol is not while the patient is hemorrhaging.

The best time to decide who follows an abnormal result is before the result becomes abnormal.

Malpractice prevention, when done properly, is therefore not about protecting physicians from patients.

It is about protecting patients from predictable failures.

And when we do that well, physicians are protected too.

The Question I Keep Coming Back To

Across more than 30 cases, one question appears again and again:

Who owned the next step?

The radiologist found the abnormality.

The laboratory reported the result.

The nurse called the physician.

The referral was entered.

The pathology was finalized.

The blood pressure appeared on the screen.

The patient called with worsening symptoms.

Information existed.

But information without ownership does not protect a patient.

Someone has to recognize it.

Interpret it.

Communicate it.

Act on it.

And make sure the next step actually happened.

That is where The MedMal Room will live.

Why I Am Making This a Series

These cases are too important for a single article.

Over the coming months, paid subscribers to ObGyn Intelligence will receive the full MedMal Room series, one case at a time.

Not sensationalized courtroom stories.

Not generic “risk-management tips.”

Each article will examine the medicine, the evidence, the ethics, the systems failure, and the lesson clinicians can actually use.

Some cases will make you agree immediately.

Others may make you uncomfortable.

A few may make you rethink practices you have considered routine for years.

That is exactly the point.

Because the most valuable malpractice case is not the one we win or lose.

It is the one we learn from before it happens again.

If you are an obstetrician, gynecologist, MFM specialist, fertility physician, midwife, nurse, resident, medical student, risk manager, or simply interested in how medicine succeeds and fails, I hope you will join me in The MedMal Room.

There are already more than 30 cases waiting.

And every one of them asks the same ultimate question:

What could we learn from this case before the next patient walks through the door?

A fetal heart rate suddenly deteriorates.

A patient hemorrhages.

A woman with hypertension has a seizure.

Everyone runs.

The obstetrician arrives. An emergency cesarean is performed. Blood is ordered. Anesthesia responds. The neonatal team begins resuscitation.

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Later, when the case is reviewed, everyone asks the obvious question:

What happened during those final minutes?

Sometimes that is the wrong question.

The more important question may be:

What happened during the hours, days, or even weeks before the emergency?

That is where some of the most important failures in obstetric care occur.

The Last 20 Minutes Are Seductive

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In Vitro Fertilization (IVF) is a medical marvel that has brought immense joy to countless families. Yet, the public narrative often simplifies it to a single, miraculous procedure. As an obstetrician, an ethicist, and a professor, I believe patients deserve a more comprehensive, candid guide to the realities of IVF. This is a complex, emotionally taxing, and financially burdensome process that begins long before a fertilized egg is transferred. It is a journey that requires not just medical intervention, but a profound commitment from both partners.

The Foundations: Learning the Basics of Fertility

Before considering IVF, a couple must understand the fundamentals of their own fertility. The rush to high-tech solutions often bypasses a thorough investigation of the basics, which can sometimes reveal simpler, less invasive paths to parenthood.

For patients: You and your partner should first understand your individual fertility profiles. This includes tracking ovulation cycles, understanding hormonal fluctuations, and recognizing potential signs of underlying issues. Knowledge is your first and most powerful tool.

For providers: It is our ethical duty to ensure a couple has exhausted all less invasive options before recommending IVF. This includes a full fertility workup, which can involve hormone testing, ovulation tracking, and a comprehensive semen analysis.

The Whole-Body Approach: Weight, Diet, and Sperm Health

A crucial, yet often under-emphasized, part of the IVF journey is optimizing the health of both partners. IVF is not a substitute for a healthy body; it is a procedure that is most successful when used in conjunction with a healthy lifestyle.

For patients: Your weight and diet can profoundly impact the success of IVF. If you are overweight or obese, losing even 5-10% of your body weight can significantly improve ovarian response and pregnancy rates. This also applies to the male partner, as a healthy diet and optimal weight are directly linked to sperm quality and motility. You should both work towards a balanced diet rich in antioxidants, lean proteins, and healthy fats.

For providers: We have an ethical obligation to discuss these lifestyle changes with our patients. Frame this not as a criticism, but as a critical part of a successful treatment plan. Providing resources for nutritional counseling and weight management is a key component of comprehensive care.

Do You Really Need IVF? The Quest for a Definitive Diagnosis

The question "Do we really need IVF?" is one that every patient should ask and every provider should be prepared to answer with absolute honesty. There are often other, less drastic ways to find the "absolute reason" for infertility.

For patients: Demand a full diagnostic workup to pinpoint the exact cause of infertility. This should include a hysterosalpingogram (HSG) to check for blocked fallopian tubes, advanced hormonal panels (FSH, LH, AMH), and a detailed, multi-parameter semen analysis. Do not accept a generic "unexplained infertility" diagnosis without a thorough investigation.

For providers: The ethical imperative is to conduct a complete diagnostic journey before recommending IVF. A patient should never feel they are being rushed to a procedure without a clear understanding of the underlying cause. IVF is not a one-size-fits-all solution, and for many couples, the problem may be surgically correctable or responsive to simpler therapies.

The Financial and Emotional Toll of IVF

IVF is a grueling process, not just physically, but financially and emotionally. The costs can be staggering, often reaching tens of thousands of dollars per cycle, and a single cycle is rarely enough. These financial pressures, combined with the emotional rollercoaster of hope and disappointment, can strain even the strongest relationships.

For patients: Be prepared for the emotional and financial realities. The journey can feel like a part-time job, with frequent clinic visits, injections, and blood draws. Seek emotional support from therapists or support groups that specialize in infertility.

For providers: We must be transparent about the financial burdens and emotional complexities of IVF. Discuss the need for multiple cycles, potential out-of-pocket costs, and the importance of mental health support.

A High-Risk Journey: IVF Pregnancies Are Not All the Same

What is often not told to patients is that an IVF pregnancy, by its very nature, is automatically considered high-risk. This is not to cause alarm, but to emphasize the need for heightened vigilance and specialized care.

For patients: Be prepared for a different level of care compared to a spontaneous pregnancy. You will likely have more frequent ultrasounds, doctor's appointments, and monitoring. This is a proactive measure to ensure the best possible outcome for you and your baby.

For providers: It is our ethical and clinical duty to classify all IVF pregnancies as high-risk from the outset. This ensures that the patient receives the specialized care they need, from a higher frequency of fetal monitoring to a more vigilant watch for complications such as preeclampsia and placental issues. A multidisciplinary team, including maternal-fetal medicine specialists and neonatologists, should be involved in the patient's care from the very beginning.

Potential Complications in IVF Pregnancies:

• Placental Abnormalities: There is a statistically higher risk of conditions such as placenta previa and placental abruption.

• Preeclampsia and Gestational Hypertension: The risk of these conditions is elevated in IVF pregnancies.

• Preterm Labor and Low Birth Weight: IVF pregnancies, particularly those with multiple gestations, have a higher risk of preterm birth.

• Chromosomal and Congenital Abnormalities: While not due to the IVF process itself, the underlying reasons for infertility can sometimes be associated with a slightly increased risk of certain conditions.

In conclusion, IVF is an incredible tool, but it is not a magic bullet. By providing patients with the full, unvarnished truth about the entire process—from the initial workup to the high-risk nature of the pregnancy itself—we can empower them to navigate this complex journey with knowledge and confidence. This is the essence of true obstetrical intelligence: a commitment to full transparency, grounded in academic rigor and profound compassion.

Every time these numbers come up, the explanation arrives fast: Black women have more C-sections because of racism.

It is a clean story. It fits what we already believe. And when I hold it against the data, it comes apart — in ways that should bother both sides of the argument.

Start with the fact, because it is real and it is large. In 2024, Black women in the United States were delivered by C-section 37.5 times out of every 100 births. White women, 31 times. The gap does not shrink when you look only at the lowest-risk births — first-time mothers, one baby, head-down, carried to term. There it is still about 31 in 100 for Black women and 26 in 100 for white women. And the gap has grown. In 2016 it was about half as wide. In the 1980s, Black women actually had fewer C-sections than average. A gap that grows over forty years is not written in anyone’s biology.

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Some of it is real medicine

Part of the difference is not bias at all. It is illness.

Black women carry more of nearly every condition that leads to a surgical birth. Fibroids — benign muscle growths in the uterus that can block a normal delivery — appear in more than 80 out of 100 Black women by age 50, against about 70 out of 100 white women, and they roughly double the chance of a C-section.

High blood pressure in pregnancy is more common: about 21 in 100 versus 15 in 100. Obesity, which makes labor harder and longer: 57 in 100 versus 40 in 100. And most sobering, the risk of stillbirth is more than twice as high. A group carrying that much more risk should have more medically needed surgery. That is good care, not prejudice.

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The comfortable rebuttal that also fails

When the illness explanation runs out, the popular answer is the hospital. Black women give birth in a smaller set of hospitals that do more C-sections, so the system sorts them into surgery. The sorting is real. But when researchers ran the experiment on paper — moving Black women to the same hospitals where white women deliver — the gap in low-risk C-sections barely closed. Even insurance, which I have long argued matters more than race for whether a mother survives childbirth, does not explain this one. The gap follows the patient, mostly inside the same buildings.

The test that actually matters

So is it the doctor in the room? One study was built to answer exactly that. Researchers took 726 birth providers and showed them identical fetal monitor strips. The only thing they changed was the patient’s race — Black or white.

The providers chose surgery at the same rate for both.

No bias in the decision that produces most C-sections.

And when women themselves ask for a C-section with no medical reason, Black women ask less often, not more. The loudest version of the story is the one the cleanest evidence supports least.

Where a real driver hides

Here is a cause that does hold up, and it is worth sitting with. For years, the calculator doctors used to predict whether a woman could safely deliver vaginally after a prior C-section had race built into its math. It handed Black women lower odds, which nudged them toward another surgery — even though Black women were more likely to try a vaginal birth and less likely to suffer the complication everyone feared. That was not a cruel doctor. It was a biased equation, used in good faith. It was removed in 2021. That is what a real structural driver looks like: specific, written down, and fixable.

What it means for you

If you are a patient, the lesson is not that your doctor is against you. It is to ask what your C-section is actually for. Ask about your own risks — your blood pressure, your fibroids, your blood sugar. And if you have had a C-section before, ask whether a vaginal birth is still on the table, because for years the tool that answered that question was quietly wrong.

My Take

The higher Black C-section rate is not bedside racism — the experiment says no, and women’s own choices point the other way. It is not simple biology — the gap grew, and some hospitals erase it completely. It is three things stacked together: real illness that calls for real surgery, one broken tool we have finally started to fix, and a leftover gap, about half of it, that honest researchers cannot yet explain. “We cannot explain it yet” is not the same as “racism.” One is an excuse to stop looking. The other is an instruction to keep going. We should keep going.

A note on how this was researched

I researched this piece with an AI — Claude, running its Fable 5 model — and then checked every number against the original sources: the CDC’s birth records and the published studies, each with a real citation. I use these tools the way Daniel Kahneman taught me to treat my own judgment: as something to check, never to trust on faith. The machine finds and organizes. The positions are mine.

Bottom line

Before you repeat the easy answer, look at what the data actually say. Share this with a colleague who still believes the gap has one simple cause. ObGyn Intelligence is free because the evidence should travel. If you want to keep it independent, a paid subscription does exactly that.

References

1. Osterman MJK, Hamilton BE, Martin JA, Driscoll AK, Valenzuela CP. Births: final data for 2024. Natl Vital Stat Rep. 2026;75(2).

2. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: final data for 2016. Natl Vital Stat Rep. 2018;67(1).

3. Main EK, Chang SC, Tucker CM, Sakowski C, Leonard SA, Rosenstein MG. Hospital-level variation in racial disparities in low-risk nulliparous cesarean delivery rates. Am J Obstet Gynecol MFM. 2023;5(11):101145. PMID: 37648109.

4. Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188(1):100-107. PMID: 12548202.

5. Li H, Hu Z, Fan Y, Hao Y. The influence of uterine fibroids on adverse outcomes in pregnant women: a meta-analysis. BMC Pregnancy Childbirth. 2024;24:345. DOI: 10.1186/s12884-024-06545-5.

6. Ford ND, Cox S, Ko JY, et al. Hypertensive disorders in pregnancy and mortality at delivery hospitalization — United States, 2017–2019. MMWR Morb Mortal Wkly Rep. 2022;71(17):585-591.

7. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief No. 360; 2020.

8. Pruitt SM, Hoyert DL, Anderson KN, et al. Racial and ethnic disparities in fetal deaths — United States, 2015–2017. MMWR Morb Mortal Wkly Rep. 2020;69(37):1277-1282. PMID: 32941410.

9. Bane S, Mujahid MS, Kan P, Main EK, Carmichael SL. Can birth hospital explain racial/ethnic differences in cesarean birth among low-risk births? An analysis of California data, 2007-2018. J Racial Ethn Health Disparities. 2026;13(4):2893-2904. PMID: 40327292.

10. Aron DC, Gordon HS, DiGiuseppe DL, Harper DL, Rosenthal GE. Variations in risk-adjusted cesarean delivery rates according to race and health insurance. Med Care. 2000;38(1):35-44. PMID: 10630718.

11. Edwards SE, Class QA, Ford CE, Alexander TA, Fleisher JD. Racial bias in cesarean decision-making. Am J Obstet Gynecol MFM. 2023;5(6):100927. PMID: 36921720.

12. Swain CA, Anderson MC, Shirazi A, Torrente S, Okwandu IC. Racial and ethnic trends in cesarean delivery on maternal request. J Racial Ethn Health Disparities. 2026. PMID: 39775743.

13. Grobman WA, Sandoval G, Rice MM, et al. Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity. Am J Obstet Gynecol. 2021;225(6):664.e1-664.e7. PMID: 34043983.

14. Cahill AG, Stamilio DM, Odibo AO, et al. Racial disparity in the success and complications of vaginal birth after cesarean delivery. Obstet Gynecol. 2008;111(3):654-658. PMID: 18310368.

“Every new medical technology promises physicians more time with patients. Too often, it gives health systems more patients per physician.”

For two centuries, medicine has repeatedly declared that physicians were becoming obsolete.

The stethoscope would replace listening.

The laboratory would replace clinical judgment.

Radiology would replace physical examination.

Evidence-based medicine would replace experience.

Electronic health records would replace memory.

Now, according to many commentators, artificial intelligence will replace physicians.

I disagree.

What AI is replacing is something different.

It is replacing the scarcity of medical knowledge.

For most of history, physicians possessed something their patients could not access.

Knowledge.

Experience.

Interpretation.

If you wanted to understand preeclampsia, placenta accreta, or recurrent pregnancy loss, you had one realistic option.

Ask your doctor.

That monopoly has disappeared.

Today every patient carries an extraordinarily capable medical information system in a pocket.

Patients arrive already informed, sometimes correctly, sometimes incorrectly, but almost never uninformed.

That changes medicine forever.

The physician is no longer the gatekeeper of information.

The physician becomes the interpreter of information.

That is a profound difference.

A recent JAMA Perspective argues that physicians are losing their “aura,” the unique authority that historically surrounded medical expertise. The author compares today’s AI revolution with photography’s disruption of painting. When reproductions became possible, painters did not disappear. They reinvented themselves. Physicians, he argues, must now do the same.

I think that analysis is only half right.

Medicine has already been losing that aura for decades.

Evidence-based guidelines replaced individual authority with standardized recommendations.

Electronic health records transformed physicians into documentation specialists.

Quality metrics replaced professional discretion with measurable performance.

Artificial intelligence did not begin this process.

It simply exposed it.

The mistake many physicians are making is believing that the competition is AI.

It is not.

The competition is the physician who knows how to use AI well.

Throughout medical history, new technologies have never eliminated competent physicians.

They have eliminated physicians who refused to adopt better tools.

Ultrasound did not replace obstetricians.

Obstetricians who mastered ultrasound replaced those who did not.

The same happened with laparoscopy.

With fetal echocardiography.

With genomics.

Large language models are following exactly the same pattern.

For obstetricians, the implications are immediate.

Our specialty depends on enormous amounts of constantly changing information.

Guidelines.

Drug safety.

Genetics.

Ultrasound.

Ethics.

Population studies.

No physician can memorize all of it.

Nor should we try.

The new competency is no longer remembering every recommendation.

It is knowing how to retrieve, verify, interpret, and apply evidence better than anyone else.

That is not a technological competency.

It is a professional one.

This requires a different educational model.

Residency programs should no longer ask only whether trainees know the answer.

They should ask whether trainees know how to obtain the best answer.

Can they supervise an LLM?

Can they detect hallucinated references?

Can they recognize outdated guidelines?

Can they critically compare competing recommendations?

Can they explain the evidence to a frightened patient?

Those are becoming essential clinical skills.

Ironically, AI may make physicians more human.

If documentation, literature searches, and administrative writing increasingly become automated, physicians regain something far more valuable than efficiency.

Attention.

Listening.

Judgment.

Empathy.

Those were never threatened by AI.

They were threatened by paperwork.

The future obstetrician will not be remembered because they memorized the most guidelines.

They will be remembered because they asked the best questions, interpreted the evidence most wisely, recognized when the AI was wrong, and remained fully accountable for every decision.

That is why I do not believe physicians are losing their role.

Our role is becoming clearer.

Medical knowledge is no longer scarce.

Clinical judgment still is.

And that may become the most valuable skill of all.

Medicine has a communication problem.

We publish thousands of pages of clinical guidelines, systematic reviews, and consensus statements every year. We congratulate ourselves on being evidence based. Yet ask clinicians a few months later about the key recommendations, and many struggle to recall them accurately.

The problem is not intelligence.

It is how the human brain works.

We remember stories better than lists. We remember patterns better than paragraphs. Most of all, we remember images better than text.

That is why a single well-designed infographic can have greater educational impact than ten pages of carefully written prose.

See one of mine here: https://www.linkedin.com/posts/obmd_httpslnkdinghz-n6y3-share-7490666217049903104-Ul8m/?utm_source=share&utm_medium=member_desktop&rcm=ACoAAA7ytecBUkDnkjRIBeYLpS15yH5ODkVGj_U

Medical education has been built around words. Medical learning depends on visuals.

The irony is striking. Radiologists diagnose from images. Obstetricians interpret ultrasound. Pathologists examine slides. Cardiologists read echocardiograms. Every specialty depends on visual pattern recognition. Yet when we teach, we often abandon the very language the brain is best equipped to process.

A dense page of recommendations requires sustained attention, working memory, and repeated reading. A thoughtfully designed infographic immediately reveals relationships, priorities, algorithms, and exceptions. It reduces cognitive load while increasing retention.

This is not about making medicine simplistic.

It is about making complex information understandable.

An effective infographic is not decoration. It is a cognitive tool.

Unfortunately, many medical graphics fail because they try to summarize rather than teach. They are crowded with tiny fonts, unnecessary icons, decorative colors, and enough text to recreate the original paper. These are illustrations, not educational tools.

A great infographic has a different purpose. It answers one clinical question. It guides one decision. It highlights what clinicians are most likely to forget. It is remembered weeks later because it transforms information into a visual mental model.

As artificial intelligence becomes integrated into medicine, this distinction becomes even more important.

Large language models can now summarize almost any paper in seconds. Text is becoming abundant. The scarce resource is no longer information. It is attention and memory.

The future of medical education will not belong to those who produce the most content. It will belong to those who communicate most effectively.

Medical journals, professional societies, hospitals, and educators should stop treating infographics as optional marketing material. They should become an expected part of scientific communication, designed with the same rigor as the manuscript itself.

Because education is not measured by what we publish.

It is measured by what clinicians remember at the bedside.

If you want people to understand, write.

If you want them to remember, show.

I have been watching Malpractice, a British medical drama on ITV. Season 2 centers on the obstetrics and psychiatry departments of an NHS hospital in Leeds/UK, where a psychiatric registrar finds himself caught between two patients on a chaotic night shift and a new mother dies.

What follows is not a courtroom thriller.

It is something more interesting: a dedicated team called the Medical Investigation Unit — the MIU — systematically pulling apart what happened, who knew what, when the moment of no return arrived, and whether the institution itself created the conditions for the outcome. The show is fiction, but the structural question it raises is real. Britain has built, at least on television, a model worth examining. The United States has not built one at all.

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We have malpractice litigation. We have risk management departments whose primary function is legal defense. We have mortality and morbidity conferences that, in most institutions, operate under a culture of self-protection rather than honest inquiry. What we do not have is an independent, structured, blame-free investigation process applied systematically to obstetric adverse outcomes. What we have instead is the NTSB — but only for airplanes.

What the NTSB Is, and Why It Works

The National Transportation Safety Board was established in 1967 by President Lyndon B. Johnson as part of the Department of Transportation Act. It became fully independent in 1975, after Congress concluded that no agency can investigate safely if it is answerable to the same body it is investigating. That independence is the core of the model.

Since 1967, the NTSB has investigated more than 153,000 aviation accidents. It has issued more than 15,500 safety recommendations to more than 2,470 recipients. Roughly 82 percent of its closed recommendations have been implemented. Aviation is one of the safest forms of transportation in human history, and a significant part of the reason is that when something goes wrong, a dedicated independent agency finds out exactly why — and tells everyone.

The methodology is specific. When a crash occurs, the NTSB dispatches a “Go Team” — between three and a dozen specialists — to the scene immediately. Each specialist investigates a defined domain: operations, structures, systems, human performance, air traffic control, survival factors. Nobody is asked to assess their own department. Nobody has a financial interest in the outcome. The investigation produces a probable cause determination — not a verdict, not a punishment — and a set of safety recommendations addressed to whoever has the power to make the relevant change.

Three features make the NTSB model work. First, independence: the investigators are not employed by the airline, the manufacturer, or the regulator. Second, scope: the investigation examines the whole system, not just the individual at the center of the event. Third, purpose: the goal is a safety recommendation, not a legal judgment. Fault is documented when relevant, but blame is not the product. Prevention is the product.

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What ObGyn Adverse Outcome Review Looks Like in the United States

A woman dies in labor. Or a baby is born with hypoxic-ischemic encephalopathy, with injuries that will define the next several decades of a family’s life. What happens next?

In most American hospitals, the answer runs roughly as follows. Risk management is notified. The chart is reviewed, usually by people with a professional interest in the outcome of any future litigation. A peer review process may occur, protected from legal discovery in most states under peer review statutes. If a malpractice claim is filed, attorneys take over. Settlements are reached, often confidential. The case closes.

What is almost never produced: a structured, independent, systematic analysis of what happened, what the standard of care required at each decision point, whether there was a deviation, and whether that deviation caused the outcome. What is almost never shared: the findings with the team that was involved, the department that shares the same workflows, the institution that uses the same protocols.

The lesson, if there is one, dies with the case. The next team walks into the same system.

The British Model — and Its Limitations

Malpractice is not a documentary. The MIU it depicts moves faster than any real investigation, has access to information that would take months to subpoena in practice, and resolves its cases in five episodes. But the structural argument the show makes is sound: there is value in an entity whose only job is to find out what happened, without being answerable to the hospital, the insurer, the licensing board, or the family’s attorneys.

The United Kingdom does, in fact, have mechanisms that move in this direction. NHS England operates the Healthcare Safety Investigation Branch, now the Health Services Safety Investigations Body (HSSIB), an independent body that investigates patient safety incidents with a stated commitment to learning rather than blame. It is not a perfect analogue to the NTSB. It does not have the same independence, the same resources, or the same cultural authority. But the principle is there.

The United States has nothing comparable for medicine. The Joint Commission accredits hospitals and reviews sentinel events, but it is neither independent nor focused on systemic learning. State medical boards investigate licensing matters. Malpractice litigation produces discovery, but it is adversarial by design — structured to assign liability, not to understand causation. None of these is the NTSB.

What We Should Do

I am not naive about the politics of this proposal. The malpractice liability system in the United States creates enormous disincentives for transparency. Hospitals and clinicians resist independent investigation precisely because findings could be used in litigation. Any serious move toward an NTSB-style model for medicine would require federal legislation granting investigation findings the same protection from legal discovery that exists for aviation accident reports.

That protection already exists in aviation. NTSB findings and the cockpit voice recordings that inform them are not admissible in civil litigation. That is not an accident. Congress made a deliberate choice that safety learning was more valuable than litigation ammunition. We have not made that choice for medicine.

The recommendation I would make to ACOG, SMFM, and Congress is this: create an independent obstetric adverse outcome investigation board, modeled on the NTSB. Give it independence from CMS, the Joint Commission, state licensing boards, and the insurance industry. Give its findings the same legal protection from discovery that aviation investigation reports carry. Fund it. Require that every maternal death, every intrapartum fetal demise, every case of birth-related hypoxic-ischemic encephalopathy be reported to it. Require that its recommendations be tracked and their implementation publicly reported.

Some countries have moved in this direction. The Netherlands has a maternal mortality review process with independent investigators. The United Kingdom has MBRRACE-UK, the confidential inquiry into maternal deaths, which produces population-level learning that has measurably improved practice. Australia has the Consultative Councils on Obstetric and Paediatric Mortality and Morbidity. The United States, which spends more on maternity care than any country in the world, has no equivalent.

What We Can Do Right Now

Waiting for Congress is not a strategy. What ObGyn departments can do right now, without legislation, is adopt the methodology even without the mandate.

The NTSB does not investigate because it is required to be heroic. It investigates because it has a structured process that it applies consistently, without exception, to every event it covers. That process can be adapted. The four legal elements of a malpractice case — duty, breach, causation, and damage — map cleanly onto a clinical investigation framework. The NTSB’s phase-by-phase approach — establish the facts, review the record, assess each decision against the standard, examine communication, examine system factors, determine causation, generate prevention recommendations — is not proprietary. It is a logic that any department can apply.

I have built a free tool that does exactly that. The ObGyn Adverse Outcome Investigation Checklist at tools.obmd.com walks a review team through all eight phases of a structured investigation, maps each phase to one of the four legal elements, and — when you are ready — lets you ask Claude to analyze the case data you have entered, identify gaps in the investigation, and generate NTSB-style prevention recommendations with specific responsible parties and deadlines.

It will not replace an independent investigation body. But it will replace the silence that currently follows most adverse outcomes in American obstetrics.

My Take

Aviation figured something out sixty years ago that medicine has still not accepted: the goal of investigating a catastrophic event is not to assign blame. It is to prevent the next one. The NTSB is not a court. It does not sentence pilots or ground airlines. It determines probable cause, issues recommendations, and tracks whether they are implemented. Its power comes entirely from the quality of its analysis and the transparency of its findings.

The show I watched on ITV is canceled after two seasons. The MIU will not be coming back. But the question it asked is not going away: who investigates when something goes wrong in medicine, and what is their goal? In the United States right now, the honest answer is: the attorneys do, and their goal is to win.

We can do better.

The NTSB shows us exactly how.

⬇ Try the EXPERIMENTAL tool

ObGyn Adverse Outcome Investigation Checklist — free, interactive, browser-based. tools.obmd.com/ob-case-review

Most doctors and clinicians use AI the same way.

Open a chat. Type a question.

Read the answer.

Close the tab.

It feels like using the tool. It is closer to wasting it. Every one of those sessions starts from zero. The AI does not know who you are, what you publish, what standards you hold, or how you write. So it gives you the average answer, written for the average person. In medicine, the average answer to your specific question is often the wrong one.

Ruben Hassid, who writes one of the largest newsletters on practical AI use, estimates that about nine out of ten users work exactly this way: one question, one answer, done. From what I see among colleagues, doctors are no exception. We may be worse.

We are busy, we are skeptical, and many of us tried an AI once in 2023, caught it inventing a reference, and filed the whole technology under “not ready.”

The technology was not the problem.

The setup was.

Nobody walks into an operating room and starts cutting.

We check the instruments, the bookings, the consent, the team. Then we start. AI rewards the same habit, and almost no one in medicine has been told this.

The gap between doctors who set up their AI and doctors who do not is now, in my view, wider than the gap between any two AI models.

What follows is the exact setup I use, written so you can copy it this weekend. Paid subscribers read on.

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What happens in the next 60 seconds, and in the hours and days that follow, is the sharpest test of what medicine owes its patients.

No other clinical moment so fully exposes the difference between communicating with warmth and being genuinely present to another person’s suffering. The word for that presence is compassion. Empathy is its precondition, not its fulfillment. And the distinction matters here more than anywhere else in obstetrics.

What Compassion Means in This Room

• Empathy is the capacity to perceive and resonate with another person’s emotional state. A clinician who walks into the room where a stillbirth has just been confirmed and recognizes the enormity of what that mother is experiencing is demonstrating empathy. An AI chatbot can produce language that registers the same recognition. Studies show patients rate such language as more empathic than what physicians typically provide.

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• Compassion goes further. It is empathy plus the commitment to act on what you perceive, to stay in it, to let the patient’s reality matter to you personally, and to do something about the fact that it matters. In a stillbirth, compassion means the clinician who does not rush the confirmation, who does not default to clinical language to manage her own discomfort, who tells the mother what she saw and then waits through the silence that follows. It means staying in the room. It means asking the mother what she wants, and meaning the question.

Stillbirth is defined as fetal death at or after 20 weeks of gestation.

In the United States, the stillbirth rate is approximately 5.7 per 1,000 births, with Black women experiencing rates nearly twice those of white women.

Behind those numbers are individual women who were pregnant, who had names for their babies, and who will remember with complete clarity how they were told. What they remember is not whether the words were warm. It is whether someone was with them.

Free readers see above. Paid subscribers continue below.

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The first clinician told her this was normal.

The second ordered thyroid labs.

The third spent eight minutes with her and said they could discuss hormone therapy when her symptoms were more established.

She downloaded an app.

That story is not exceptional. It is the median experience of perimenopause care in the United States. And the AI empathy research, which finds that patients rate chatbot responses as more empathic than physician responses, finds its most politically uncomfortable confirmation in menopause care.

The chatbot is more empathic because the clinician has not been there at all.

The Compassion Deficit in Menopause Care

Empathy in a menopause appointment means the clinician hears that a patient’s quality of life is significantly impaired and acknowledges that this matters. Compassion means being moved to act on it: to take the symptom burden seriously, to know the evidence well enough to offer effective treatment, and to stay with the patient across the transition rather than managing the appointment efficiently and moving on.

The menopause transition affects 100 percent of women who live long enough. Vasomotor symptoms affect approximately 75 percent of women, with roughly 25 percent describing severe, life-disrupting symptoms.

Genitourinary syndrome of menopause affects the majority of postmenopausal women and is underreported, underdiagnosed, and undertreated at rates that would be considered a clinical crisis if the affected organ were anything other than the vagina.

The evidence on menopausal hormone therapy has been substantially clarified since the Women’s Health Initiative findings were misread and misreported in 2002.

For healthy women under 60 or within 10 years of menopause onset, the benefit-risk profile of hormone therapy is favorable for most women with significant symptoms. The clinician who is still reflexively withholding hormone therapy in 2025 without individualized risk assessment is not being cautious. She is being undertrained, and her patient is paying for it in years of disrupted sleep, impaired cognition, and reduced quality of life.

Free readers see above. Paid subscribers continue below.

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He was competent, thorough, and honest.

We had reviewed the case together in detail.

The clinical picture was clear.

Something had gone wrong, and the pathway by which it went wrong was identifiable.

We both understood what it was.

I turned to him and said: given what we have found, what do you recommend we change to prevent this from happening again?

He looked at me with an expression I have thought about many times since. Not defensive. Not evasive. Genuinely puzzled.

“That is not my responsibility,” he said. “I am not a doctor. It is not my place to make clinical recommendations.”

He was correct on every count.

It was not his responsibility.

He was not a doctor.

It was not his place.

And that, I realized, is one of the central problems with how American medicine handles adverse outcomes. When the case is over, nobody whose job it is to understand what went wrong has a job that includes recommending what should change. The lawyer protects the institution. The risk manager documents the event. The peer reviewer assesses the individual clinician. The M&M conference discusses the case. And then everyone returns to their lane.

Prevention is in nobody’s lane.

Each Person Does Their Job. Nobody Does the One That Matters.

This is worth sitting with. The hospital lawyer in that room was not indifferent to the outcome. He was a professional doing exactly what he had been hired to do: assess liability, manage exposure, protect the institution’s legal position. Recommending clinical practice changes was genuinely outside that mandate. If he had made such recommendations, he would have been operating outside his expertise and potentially creating additional liability for his client.

The risk manager’s job is documentation and compliance. The quality officer’s job is accreditation. The peer reviewer’s job is to assess whether the clinician met the standard of care. The malpractice insurer’s job is to settle or defend. Each of these roles is real, each is occupied by capable people, and none of them has prevention as its primary output.

The NTSB understood this problem sixty years ago. Its founding mandate was not to assign blame, not to manage liability, not to protect any party’s legal position. It was to determine probable cause and issue safety recommendations. Prevention was not a byproduct of the NTSB’s work. It was the only product. Every other output -- the investigation report, the probable cause determination, the factual reconstruction -- exists in service of the safety recommendation.

In the room where I sat with that lawyer, there was no NTSB equivalent. There was no person or body whose only job was to ask: what changes would prevent the next case?

The Lawyer’s Constraint Is a System Design

I want to be precise about what the lawyer’s response revealed, because it is easy to hear it as an excuse and miss what it actually was: an accurate description of how the system is built.

The American hospital response to an adverse outcome is organized around two functions: legal defense and regulatory compliance. Both are legitimate. Both are necessary. Neither is designed to produce prevention. Legal defense is designed to minimize liability. Regulatory compliance (the Joint Commission root cause analysis, the peer review process, the sentinel event report) is designed to satisfy an accreditor. These are different goals from prevention, and optimizing for them does not automatically produce prevention as a side effect.

In fact, optimizing for legal defense actively works against prevention in one specific way: it creates strong incentives not to produce a written document that clearly identifies what went wrong and what should change. Such a document, if not properly protected, becomes discoverable evidence. The instinct of every legal team I have ever worked with is to produce the minimum documentation necessary to satisfy the accreditor while preserving the maximum possible ambiguity about causation.

The NTSB solved this problem legislatively. Under 49 U.S.C. Section 1154(b), no part of an NTSB accident report may be admitted into evidence in a civil lawsuit arising from the accident. Congress made an explicit choice that safety learning was worth more than litigation ammunition. That protection is why NTSB investigators can write exactly what they found without worrying about what plaintiff’s attorneys will do with it.

Medicine has never made that choice. And so the lawyers remain in their lane, the investigators remain in theirs, and the written record of what went wrong remains as vague as possible. Prevention waits.

Who Should Have That Job

The answer the NTSB model provides is: a person or body whose only job is prevention, who is independent of all the parties with a financial interest in the outcome, and whose work product is a safety recommendation addressed to whoever has the power to make the relevant change.

That body does not currently exist in American obstetrics.

What should exist is an Obstetric Patient Safety Investigation Board, independent of ACOG, independent of hospital systems, independent of malpractice insurers, and independent of the Joint Commission, that investigates every maternal death and every case of birth-related brain injury, produces a public report, and issues safety recommendations with named recipients, measurable outcomes, and tracked implementation.

The hospital lawyer would not be asked to sit on that body. Neither would the risk manager or the peer reviewer. Those people would continue doing their jobs.

The investigation board would do a different job: the one nobody is doing now.

Until that body exists at the national level, ObGyn departments can build a local approximation of it. The investigation checklist at tools.obmd.com/ob-case-review walks a review team through the same phases the NTSB uses: establish the facts, review the record, assess each decision against the standard of care, examine communication, examine system factors, determine causation, and generate prevention recommendations addressed to whoever has the authority to make each specific change. The AI analysis that runs on the entered data produces a Safety Recommendation Report in NTSB format: specific actions, named responsible parties, deadlines, and measurable metrics.

That report gives the department chair what I did not have in that room: a document whose explicit purpose is to answer the question the lawyer could not answer.

What Needs to Change at the System Level

The lawyer’s response pointed to three specific system failures that no individual institution can fix alone.

The first is the absence of a mandated prevention function. Every hospital has a legal defense function. Every accredited hospital has a sentinel event reporting function. No hospital is required to have a function whose sole purpose is to produce safety recommendations from adverse outcome investigations and track their implementation. ACOG should require it. The Joint Commission should require it. Until one of them does, it will remain optional, which means most institutions will not have it.

The second is the absence of litigation protection for candid investigation findings. As long as a clearly written investigation report identifying a specific practice gap can be subpoenaed and used against the institution in court, the legal team’s instinct will be to prevent that document from existing. Congress needs to extend to medical adverse outcome investigations the same protection that exists for NTSB aviation reports. Without that protection, candor is professionally irrational.

The third is the absence of a prevention-focused mandate anywhere in the existing system. The lawyer’s job is defense. The risk manager’s job is documentation. The peer reviewer’s job is individual assessment. None of these roles has “prevent the next case” as its primary or even secondary function. That function needs to be explicitly assigned, resourced, and held accountable. Right now, it belongs to everyone in principle and to no one in practice.

Conclusion

I do not blame that lawyer.

He did exactly what he was hired to do, and he was honest with me about what he could and could not contribute.

That honesty was more valuable than a vague promise to “look into it” that would have produced nothing.

What I learned from that conversation is that the gap in American obstetric patient safety is not primarily a gap in competence or in caring.

The clinicians involved in most adverse outcomes are competent.

The lawyers are competent.

The risk managers are competent.

The gap is structural. The system has been designed to do everything except the one thing that would actually reduce the rate of preventable adverse outcomes: assign clear responsibility for prevention to a specific person or body with the independence, the authority, and the mandate to produce it.

The NTSB is not staffed by people who are smarter than hospital lawyers or risk managers or department chairs. It is structured differently. Its investigators have one job. Their findings are protected from litigation. Their recommendations are public and tracked. That structure is what produces results, not the intelligence of the people inside it.

We know how to build this. We have had the model for sixty years. The question is whether American obstetrics is willing to adopt it, or whether we will continue producing adverse outcomes at the current rate while each of the responsible parties continues doing their job and nobody does the one that matters.

The investigation tool

—> ObGyn Adverse Outcome Investigation Checklist -- NTSB methodology, AI-powered Safety Recommendation Report, free. tools.obmd.com/ob-case-review

Every day, women in Texas, Idaho, and other restrictive states face the same nightmare: a wanted pregnancy goes wrong, doctors hesitate, and by the time they are allowed to act, infection or hemorrhage has already taken hold. These women are not dying because medicine has failed them. They are dying because the law forbids doctors from doing what they know is right.

And while this happens, the very medical societies that claim to represent these physicians hold their conferences, fundraisers, and board meetings in those same states. Some even keep their headquarters there. The symbolism is impossible to ignore: our institutions are thriving in the same places where their patients are suffering.

The Ethics of Geography

Texas is a case study. Its abortion ban has already driven obstetricians out, closed maternity wards, and caused preventable deaths. Yet major national medical organizations continue to meet there, dine there, and thank local officials for hosting them. They talk about “advocacy,” but their physical presence lends legitimacy to a system that endangers women and criminalizes doctors.

A headquarters is not neutral. It is a statement of alignment. When a society rooted in evidence-based medicine plants itself in a state that outlaws that same evidence, it undermines its credibility. It tells its members: we’ll defend your ethics from afar, but we’ll enjoy the hospitality of those who deny them.

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The Quietness

Many societies say they “stand with patients” while issuing cautious, lawyer-reviewed statements that offend no one and protect nothing. They call for “further study” of laws that have already caused deaths. They avoid using the word “abortion” in official publications, replacing it with phrases like “pregnancy termination.”

This is not diplomacy.

History will not remember the tone of their statements. It will remember the women who died while their professional defenders stayed comfortable.

What Leadership Looks Like

Real leadership in medicine means taking risks for patients, not for public relations. It means refusing to hold meetings in states where the law criminalizes standard care. It means relocating headquarters if necessary, the way organizations once boycotted states that violated civil rights. It means turning polite support into visible solidarity.

Some will say this is “too political.” But so was washing your hands in Semmelweis’s time. So was fighting for contraception and racial equality in hospitals. Ethics becomes political whenever law turns unjust.

What Our Societies Could—and Must—Do

They could publish and maintain a public list of women harmed or killed by abortion bans, with verified cases drawn from public health data and investigations. Not as propaganda, but as remembrance and accountability. Every woman lost should have a name, a face, and a date. Numbers move minds, but names move consciences.

They could maintain a companion list of hospitals where physicians have been disciplined or threatened for providing standard care.
They could establish legal-defense funds for clinicians prosecuted under abortion bans.
They could commit to hosting conferences only in states where reproductive care is lawful.
They could move their headquarters out of states that criminalize their own members.
And most of all, they could name—not hint at—the laws that kill.

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The Moral Math

Every time a society chooses Texas or Florida or Idaho as a venue, it sends money, visibility, and legitimacy to states that have chosen ideology over women’s lives. Each banquet, photo-op, and ribbon-cutting takes place under laws that force doctors to wait until a woman is near death before acting.

That is not neutrality. That is endorsement by silence.

Reflection / Closing

Physicians across the country are showing moral courage—treating when the law says wait, speaking out when silence feels safer. Our societies owe them the same.

Ethical leadership is not measured by how carefully one avoids controversy. It is measured by how clearly one names harm and how boldly one refuses to stand on its soil.

If our medical institutions truly believe that abortion is health care, then they must stop holding meetings—and their moral ground—in states where medicine itself is under attack. And they must bear public witness to every woman who suffered because they didn’t speak loudly enough, soon enough, or often enough.

A woman at 19 weeks arrives for her anatomy scan. She has brought her partner. She has the gender reveal planned for Saturday. The sonographer takes longer than usual. She asks twice whether everything is okay. The sonographer says the doctor will come in to talk. The doctor comes in and begins explaining what she found. The patient hears the first sentence and stops hearing the rest.

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That moment, when a normal pregnancy becomes a pregnancy with a diagnosis, is among the most demanding in all of perinatal medicine.

What happens in the next hour and the next 72 hours determines how a patient navigates a decision that is among the most consequential of her life.

The clinical system was not designed for that moment.

And the AI tools now entering prenatal diagnosis counseling have not reckoned with what it actually requires.

What the Moment Requires

Empathy in this room means recognizing the shock and being moved by it. Compassion means acting on that recognition: slowing down, checking what the patient has actually heard, deciding what information should come now and what should wait, and making clear that this is the beginning of a supported process and not the delivery of a verdict. Those are clinical judgments, not communication techniques.

Major structural fetal anomalies are identified in approximately 2 to 3 percent of pregnancies screened with detailed anatomy ultrasound.

The range is wide: from conditions compatible with normal life requiring postnatal surgery, to conditions incompatible with survival, to conditions whose prognosis is genuinely uncertain. What all of them have in common is that the patient was not prepared. No prenatal appointment prepares a woman for this conversation.

Research on patient experience after anomaly diagnosis consistently finds that what patients remember most is not the information they received but how they received it: whether the clinician was present to their shock, whether they were given time, and whether they felt the clinician cared about what the diagnosis meant for their specific lives.

Those are measures of compassion, not empathy.

Free readers see above. Paid subscribers continue below.

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How cognitive bias turns warning signs into background noise, and what to do about it.

She is two days postoperative. Cesarean delivery, uncomplicated by the operative note. She calls the triage line reporting shortness of breath and chest tightness. The nurse asks about her pain medications. The resident documents atelectasis, encourages deep breathing, and tells her to follow up with her doctor in a week.

She dies 18 hours later of pulmonary embolism.

This is not a hypothetical. Variants of this scenario appear throughout maternal mortality reviews on both sides of the Atlantic. The diagnosis was not difficult in retrospect. It was missed because the clinician had already decided what was wrong before fully evaluating the patient.

How Judgment Works, According to Kahneman

Daniel Kahneman spent a career documenting what the human mind does when it believes it is reasoning but is actually shortcutting. His framework, developed with Amos Tversky and extended in Thinking, Fast and Slow, distinguishes two modes of cognition. System 1 is fast, automatic, pattern-based. System 2 is slow, deliberate, effortful. The problem is that System 1 is always running, and it is often wrong in ways System 2 never gets the chance to correct. (1)

Medicine trains clinicians to trust pattern recognition. That training is not wrong. A seasoned obstetrician who sees late decelerations and immediately calls for an emergency cesarean is using System 1 appropriately. The trouble begins when System 1 generates a diagnosis before the data warrant it, and System 2 never asks whether the pattern is actually fitting the patient in front of us.

Kahneman called this substitution: we replace the question we should be asking with an easier one. What dangerous condition is this patient showing signs of? becomes What do postoperative symptoms usually represent? The second question is easier to answer. It is also the wrong question.

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What follows is an extensive insight into 4 biases we must be aware of:

1. Anchoring bias — fixing on the first piece of information (she just had a cesarean) and insufficiently updating when new symptoms arrive.

2. Premature closure — reaching a satisfying explanation and stopping the diagnostic search too early.

3. Normalization of deviance — abnormal findings gradually accepted as expected, drifting collectively across shifts and teams.

4. Normalcy bias — assuming that because things have been stable, they will remain stable, causing clinicians to underweight new deteriorating data.

ObGyn Intelligence: Safety analysis, the evidence critique, and the verdict are below -- for subscribers who want the full picture.

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When Robert F. Kennedy Jr. publicly claimed in mid-2025 that antidepressant use in pregnancy causes autism, he wasn’t just spreading misinformation. He was undermining one of medicine’s most important principles: that risk must be measured, not imagined. His statements ignored decades of data and contradicted the consensus of ACOG and others—that the benefits of treating moderate to severe depression during pregnancy often outweigh the potential risks. The challenge is not choosing sides between fear and overconfidence. It’s learning how to balance them.

What SSRIs and SNRIs Actually Are

SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin–norepinephrine reuptake inhibitors) are the most studied psychiatric medications in pregnancy. Introduced in the 1980s with fluoxetine (Prozac), these agents increase neurotransmitters that regulate mood. Common SSRIs include fluoxetine, sertraline, citalopram, escitalopram, and paroxetine. SNRIs like venlafaxine and duloxetine affect both serotonin and norepinephrine.

Over 30 years of research, including large registry studies from the U.S., Denmark, and the U.K., have shown that most SSRIs are not linked to major congenital malformations. Some small associations—like paroxetine and certain cardiac defects—exist, but absolute risks remain low. The most common neonatal effect, transient adaptation syndrome, resolves spontaneously within days. These findings have placed SSRIs among the most evidence-supported medications used in pregnancy.

But data are not the whole story. The question is not only whether SSRIs are “safe,” but whether ObGyns should be the ones to initiate them.

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The Evidence and the Risks

Untreated maternal depression and anxiety carry well-established dangers: increased risk of suicide, preterm birth, preeclampsia, low birth weight, and postpartum depression. Yet medications also have potential downsides—neonatal adaptation symptoms in about 25–30% of late-exposed infants, a very small possible association with persistent pulmonary hypertension, and a modestly higher cardiac-defect risk with paroxetine.

ACOG’s 2023 guideline emphasizes balance:

“The use of SSRIs or SNRIs during pregnancy should be individualized, weighing the benefits of treatment for the mother against potential risks for the fetus. Untreated maternal depression carries significant risk to both.”

That is not a license to prescribe freely. It is a reminder to evaluate deliberately.

When Obstetricians May Consider Initiating SSRIs

In some cases, obstetricians may appropriately initiate SSRI treatment for mild to moderate depression or anxiety, particularly when psychiatric access is limited. However, this decision should always involve collaboration with a mental health specialist and shared decision-making with the patient.

Factors supporting obstetrician-initiated SSRI treatment:

• Frontline access: OB-GYNs are often the first—and sometimes the only—healthcare providers to screen pregnant women for depression or anxiety. Early treatment can prevent worsening illness.

• Established standard of care: ACOG supports the role of ObGyns in initiating treatment when needed, provided systems exist for referral and follow-up.

• Continuity of stable therapy: If a woman is already well controlled on an SSRI before pregnancy, continuing the same medication is usually preferred over switching or stopping.

• Safety profile: Most SSRIs, especially sertraline, have reassuring safety data when used appropriately.

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Even so, “can” does not always mean “should.” Obstetricians occupy a crucial but limited role: we recognize illness, initiate temporary care if necessary, and connect patients to psychiatric management for ongoing treatment.

When to Refer to a Mental Health Specialist

Referral or co-management with a psychiatrist or psychologist is strongly advised in these situations:

• Severe or complex illness: Major depressive episodes with suicidality, bipolar disorder, psychosis, or OCD.

• Lack of response: Failure to improve after an adequate trial or presence of side effects requiring dose adjustments or medication changes.

• Need for psychotherapy: Cognitive behavioral or interpersonal therapy is first-line for many mild and moderate cases and should complement pharmacologic care.

• Diagnostic uncertainty: Overlapping or unclear psychiatric presentations.

• Consultation model: In collaborative care, the ObGyn serves as the primary contact while a psychiatrist provides oversight and treatment guidance.

This model keeps obstetricians within professional scope while ensuring patients receive expert mental health care.

Why Boundaries Matter

Starting an SSRI seems simple: write a prescription and follow up. But that simplicity is deceptive. Psychiatric diagnosis requires nuance—distinguishing major depression from bipolar disorder, anxiety from trauma, despair from adjustment. Missteps can cause harm, including medication-induced mania or undertreatment of serious psychiatric disease.

Obstetricians receive limited psychiatric training. We manage hypertension, diabetes, and hemorrhage expertly, but not complex psychopharmacology.

Professionalism means knowing when our reach should stop. Continuing a patient’s pre-existing SSRI? Yes. Managing her therapy in consultation with a psychiatrist? Appropriate. But initiating long-term antidepressant therapy without collaboration crosses a professional boundary.

Weighing Risks and Benefits

Every decision must be individualized:

Risks of untreated depression:

• Suicide and self-harm

• Preterm birth and low birth weight

• Preeclampsia

• Impaired bonding and increased postpartum depression

Potential risks of SSRI use:

• Neonatal adaptation syndrome (NAS): 25–30% of late-exposed infants, mild and transient

• Persistent pulmonary hypertension (PPHN): Rare, <1%, likely multifactorial

• Paroxetine: Slightly higher risk of cardiac defects; sertraline preferred

The risk-benefit discussion should be explicit, documented, and revisited as pregnancy progresses.

The Ethical Core

The debate about SSRIs is ultimately a debate about trust. Patients trust us to tell them the truth, not to minimize risk or exaggerate it. Kennedy’s falsehoods exploit public fear; uncritical prescribing exploits clinical shortcuts. Both betray that trust.

Ethical practice lies between the two extremes: recognize illness early, provide accurate information, initiate only when appropriate, and partner with psychiatry whenever possible.

Reflection / Closing:
Obstetricians should remain the first eyes, not the final hands, in managing perinatal mental illness. The pen that writes the prescription carries both power and responsibility. Using it wisely means knowing when to put it down—and when to call for help.

Picture two women in the same hospital on the same day. One has a cesarean delivery she did not need. The other needed one and did not get it in time. We have a word for the first woman: unnecessary. We have no word for the second. That silence is the whole problem.

For years, people have argued about a single number: the cesarean delivery rate. Are there too many cesarean deliveries? It is the wrong question. A rate only tells you how often the surgery happened. It says nothing about whether it should have.

Here is the question that matters. Every cesarean delivery that is done, was it the right call? And every cesarean delivery that is not done, was that the right call too? Both are decisions. Both can be wrong. We spend almost all our attention on the first and almost none on the second.

Look at three wealthy countries. In the United States, about 32 out of every 100 births in 2024 were cesarean deliveries. In Germany, it was about 33 out of 100 in 2023, the highest in that country’s history. In England, it is now about 42 out of 100.

That is a huge gap. Are English babies really sicker than American babies? Are English mothers weaker? No. The number mostly reflects local habits, fear of lawsuits, and how a hospital is run, not what mothers and babies actually need. And when you compare countries, the ones with more cesarean deliveries do not have fewer baby deaths. Chasing the rate misses the point.

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We count the cesarean delivery that should not have happened. We do not count the one that should have. And that second mistake is invisible. A low rate can look like good care while babies are being harmed.

England already lived this. In 2022, an official review of hospitals in Shrewsbury and Telford found something chilling. For twenty years, those hospitals worked to keep their cesarean delivery rate low, and they were proud of it. The review tied serious failures to the deaths of more than 200 babies and nine mothers. Some of that harm happened because a cesarean delivery that could have helped was delayed or never done. Soon after, England told its hospitals to stop treating a low cesarean delivery rate as a goal.

A cesarean delivery that is wrongly avoided has a face. It is the baby whose heartbeat is dropping while everyone waits. It is the shoulder that gets stuck during birth. It is the baby who dies during labor when a timely cesarean delivery would have prevented it. Nobody keeps a list of the cesarean deliveries we should have done. We should.

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And England is still failing, now from the other side. In June 2026, a national investigation led by Baroness Amos looked at 12 hospitals. In every one, it found women who were not listened to and were shut out of decisions about their own care. Shrewsbury kept its cesarean delivery rate low and babies died. Today England’s rate is high. The number swung all the way across. What never got fixed was the decision itself.

There is one more decision that leads straight to the operating room: starting labor with medicine instead of waiting for it to begin on its own. This is called induction, and it is rising fast. In the United States, about 35 out of every 100 labors were started this way in 2024, up from 25 out of 100 in 2016. In England it is about 1 in 3.

Starting labor early is a real decision, just like a cesarean delivery. A failed induction is one of the most common paths to an unplanned cesarean delivery. When labor is started for a weak reason, a due date on the calendar, a guess that the baby is big, a schedule that is convenient, and it ends in surgery, that is two interventions, and neither was clearly needed.

We were promised that more inductions would mean fewer cesarean deliveries. It did not happen. As inductions climbed, the cesarean delivery rate did not fall. A woman’s chance of her first cesarean delivery has actually gone up since 2019. More inductions, not fewer cesarean deliveries.

Here is my take. Stop arguing about whether the rate is too high or too low. Ask whether each choice was right. Every cesarean delivery that is done should answer one simple question: why? Every cesarean delivery that is not done should answer the same question. So should every induction that comes before them.

A woman deserves the full truth before labor, not a number and not a shrug. Tell her what the evidence shows. Tell her what you would recommend, and why. Hiding behind “it is your choice” is not respect. It is walking away. That conversation belongs before the emergency, while there is still time to think.

A number cannot protect a mother or her baby. A good reason can, offered to her honestly and in time. The newest national report says the same from the other direction: the harm was never the number, it was shutting women out of the choice. The day we take both mistakes seriously, the cesarean delivery wrongly done and the cesarean delivery wrongly skipped, is the day this debate finally grows up.

If you want women’s health explained straight, with the evidence and without the spin, subscribe to ObGyn Intelligence.

References

1. National Center for Health Statistics. Births: provisional and final natality data, 2023–2024. Centers for Disease Control and Prevention; 2024–2025. (US cesarean 32.4% in 2024; first cesarean delivery rate 22.9%, up since 2019.)

2. National Center for Health Statistics. Induction of Labor Increases in the United States: 2016–2024. NCHS Data Brief No. 554. Centers for Disease Control and Prevention; March 2026.

3. Statistisches Bundesamt (Destatis). Fast ein Drittel aller Geburten im Jahr 2023 durch Kaiserschnitt. Press release; May 2025. (German cesarean delivery rate 32.6% in 2023.)

4. NHS England Digital. NHS Maternity Statistics, England 2023–24; 2024. National Maternity and Perinatal Audit. State of the Nation report; 2025. (England cesarean deliveries ~42%; induction ~33%.)

5. Ockenden D. Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust: Final Report; 2022.

6. Amos V. Independent National Maternity and Neonatal Investigation: Final Report and Recommendations. England; 30 June 2026.

A woman goes into labor in a rural county.

The nearest hospital that still delivers babies is 90 minutes away, because the one in her town closed its maternity ward two years ago.

She makes the drive. Most times it ends fine.

Sometimes it does not. This is no longer a rare story. It is the map of American maternity care.

In 2023, 669 women died from causes tied to pregnancy in the United States. That is a rate of 18.6 deaths for every 100,000 births. It is better than the year before, and still worse than almost every other wealthy country. Most of them sit between 3 and 7 deaths per 100,000. We are two to five times higher — and we spend more per person on health care than anyone on earth.

The deaths are not spread evenly. For Black women the rate was 50.3 per 100,000. For white women it was 14.5. Same country, same year, a gap of more than three to one.

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The easy explanation is racism. Racism is real. But it is not the main lever here, and treating it as the only cause lets the real problem hide. The real problem is money. Medicaid pays hospitals and doctors about half what private insurance pays for the same birth. When a service loses money, hospitals stop offering it — and maternity is usually first to go. So the women with public insurance, who are more likely to be Black and more likely to be rural, lose access first. In countries with universal coverage, where that payment gap does not exist, the racial gap in maternal deaths largely disappears. That tells you what is actually driving it.

Maternity care deserts continue to expand across the United States, leaving many pregnant patients to travel long distances or deliver without timely access to obstetric services. Hospital closures disproportionately affect rural communities, where loss of local labor and delivery units can delay emergency care and worsen maternal and neonatal outcomes.

The closures are speeding up. Since the end of 2020, 139 rural hospitals have stopped delivering babies — about two a month. More than a third of all US counties are now maternity care deserts: 1,104 counties with no hospital, no birth center, and no obstetric provider. About 2.3 million women of childbearing age live in them.

Hospitals do not close maternity wards out of cruelty. A labor and delivery unit runs 24 hours a day, 7 days a week, whether it delivers 400 babies a year or 40. At low volume, the payments do not cover the cost of simply being ready. So the doors close.

Here is the part that should make you angry. Keeping every financially at-risk rural hospital in America open — all services, maternity included — costs about $6 billion a year. That is one-tenth of one percent of what the country spends on health care. We are choosing not to spend it.

Now look at what we did choose.

Read that last line again. Spread over 20 years, $150 billion is $7.5 billion a year, or if invested in Treasuries at 4% it’s $6 Billion a year.

More than enough to keep every at-risk rural hospital open the entire time, reopen the maternity wards that already closed, and still have money left over to start closing the payment gap that drives the deaths in the first place.

For a woman in a rural county, this is not abstract. It is the difference between a 10-minute drive and a 90-minute one when her labor goes wrong. In obstetrics, distance kills. The math above is measured in minutes on a dark highway.

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My Take

We are not a poor country that cannot afford to keep mothers alive.

We are a rich country that decided mothers are not the priority.

When we want $150 billion for a war or for enforcement, we find it in weeks.

When mothers need $6 billion a year to keep the lights on in the hospital where they deliver, we are told it is not in the budget.

That is not an economics problem.

It is a values problem.

A budget is not a spreadshee, it is a moral document. It is where a country writes down, in numbers, who it is willing to protect.

Fixing this does not take a miracle. Pay for maternity care the way we pay for a fire department: you fund it to be ready, not per fire. Close the Medicaid payment gap so a hospital is not punished for taking a woman with public insurance. Both are affordable. Both are choices we keep refusing to make.

The next time someone tells you the country cannot afford to keep mothers safe, ask them to explain the $150 billion. The money exists. The will does not.

If this made you think, subscribe. It is free, and the evidence here is better than what you will get from the people who found the money for everything except mothers.

References

1. National Center for Health Statistics. Maternal mortality rates in the United States, 2023 [Internet]. Hyattsville (MD): NCHS; 2025 [cited 2026 Jul 22]. Available from: https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2023/maternal-mortality-rates-2023.htm

2. March of Dimes. Nowhere to go: maternity care deserts across the US (2024 report) [Internet]. Arlington (VA): March of Dimes; 2024 [cited 2026 Jul 22]. Available from: https://www.marchofdimes.org/maternity-care-deserts-report

3. Center for Healthcare Quality and Payment Reform. Stopping the loss of rural maternity care [Internet]. CHQPR; [cited 2026 Jul 22]. Available from: https://ruralhospitals.chqpr.org/Maternity_Care.html

4. Center for Healthcare Quality and Payment Reform. Rural hospitals at risk of closing [Internet]. CHQPR; [cited 2026 Jul 22]. Available from: https://chqpr.org/downloads/Rural_Hospitals_at_Risk_of_Closing.pdf

5. Centers for Medicare & Medicaid Services. National health expenditure data: historical [Internet]. Baltimore (MD): CMS; [cited 2026 Jul 22]. Available from: https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/historical

6. Hegseth says Iran war has cost $37.5 billion. Bloomberg. 2026 Jul 21 [cited 2026 Jul 22]. Available from: https://www.bloomberg.com/news/articles/2026-07-21/hegseth-says-iran-war-has-cost-37-5-billion

7. What’s in the $70 billion bill funding immigration enforcement. Time. 2026 Jun 10 [cited 2026 Jul 22]. Available from: https://time.com/article/2026/06/10/house-passes-secure-america-act-senate-reconciliation-bill-funding-immigration-enforcement-trump/