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.

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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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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.

JAMA’s new patient page on the cyclosporiasis outbreak reads at a college level — so here is the same page, same facts, rewritten the way a patient page should be written.

I ran JAMA's new patient page on this outbreak through six standard readability formulas. Every one puts it at a college reading level — far above the 6th-to-8th-grade level the AMA and NIH set for patient education.

Higher Flesch Reading Ease means easier; higher grade scores mean harder. The JAMA page lands at a college sophomore-to-junior level. The rewrite below sits in the middle-school target range.

So here is the same page, rewritten the way a patient page should be written. Same facts. Same numbers. Fewer big words.

What is cyclosporiasis?

It is a stomach and gut infection. A tiny parasite causes it. The parasite is called Cyclospora. It is too small to see. It infects the small bowel and gives you watery diarrhea.

How do you get it?

You get it by eating food or drinking water that has the parasite in it. The parasite passes out in the stool of people who are already infected. From there it can end up on food.

The foods most often to blame are fresh fruits and vegetables that are eaten raw. Foods with bumps and grooves are the worst, because they are hard to clean. Think raspberries, leafy greens, and herbs.

You cannot catch it straight from another person. It has to pass through food or water first.

What does it feel like?

The main sign is watery diarrhea. You go often, and it can come on fast and hard. This usually starts 2 to 12 days after the parasite gets into your body.

You may also lose your appetite. You may feel cramps or bloating. You may have more gas, lose weight, or feel very tired.

If you do not treat it, it can last for weeks or even months. Some people feel better for a while and then get sick again.

What is going on with the outbreak?

An outbreak happens when a large batch of produce gets the parasite on it. This can happen while the food is being picked or packed. Food ships all over the country, so people in many states can get sick from the same source.

Past outbreaks have been traced to romaine lettuce, sugar snap peas, raspberries, and fresh herbs like cilantro and basil.

This outbreak was first spotted in mid-June 2026. As of July 17, the CDC had counted 1,645 confirmed cases and more than 5,100 likely cases across 34 states. The real number is probably much higher. Many people have mild symptoms and never see a doctor.

On July 16, the CDC said one part of the outbreak, in 5 states, was linked to shredded iceberg lettuce. The CDC is still looking into other cases that may come from a different food.

How do doctors find it and treat it?

A doctor tests a sample of your stool. They look at it under a microscope for the parasite’s eggs. Or they run a lab test that finds the parasite’s DNA. The eggs are hard to spot, so you may need to give more than one sample.

The usual treatment is an antibiotic called trimethoprim-sulfamethoxazole. You take it for 7 to 10 days. Most people feel better within a few days. People with a weak immune system may need it longer. Drink plenty of fluids so you do not get dried out from the diarrhea.

How can you prevent it?

The best way is to keep the parasite out of your food and water. Heat kills it, so cooked food is safe. Freezing lowers the risk but does not remove it fully.

Wash raw fruits and vegetables well under running water. Peel off or throw away the outer layer when you can, such as the outer leaves of a head of lettuce. The parasite usually sits on the outside. And wash bagged salad even if the label says it was already washed.

My take

None of this is hard to say in plain words. The facts did not change. The parasite is still the same parasite. The lettuce is still the same lettuce. All that changed is that a worried person can now read it.

A patient page that a patient cannot read is not doing its job. If we call something a public service, it should serve the public. Writing clearly is not dumbing down the medicine. It is respecting the reader.

If this was useful, subscribe. ObGyn Intelligence is free because the work matters, and clear writing should not be a luxury.

Reference

1. Linder KA, Malani PN. What Is Cyclosporiasis? JAMA. Published online July 21, 2026. doi:10.1001/jama.2026.14866. (All facts and outbreak figures in this rewrite are drawn from this JAMA Patient Page, which attributes the case counts to the US Centers for Disease Control and Prevention.)

Readability of this rewrite (body text): Flesch Reading Ease 82, Flesch-Kincaid grade 4.4, Gunning Fog 6.6, SMOG 7.9, Coleman-Liau 5.6, Dale-Chall grade 7-8. Target for patient education is 6th to 8th grade.

We have been warned relentlessly about AI hallucinations. Large language models, we are told, generate confident, authoritative text that is entirely fabricated—invented citations, fictional studies, plausible-sounding nonsense delivered without hesitation. This is a legitimate concern. OpenAI, Anthropic, and Google have invested billions in guardrails, fact-checking layers, and uncertainty quantification to mitigate the problem.

But there is a hallucination epidemic far more prevalent and far more dangerous that no one is racing to fix: the physician who, faced with a question she cannot answer, invents one. That is called ‘Confabulation’.

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Confabulation in the White Coat

It happens countless times every day in every hospital and clinic. A patient asks a question. The physician does not know the answer—or knows the honest answer is “I’m not sure” or “the evidence is unclear.” But instead of saying so, she constructs a response on the spot. It sounds authoritative. It is delivered with the confidence her training taught her to project. And it is completely untethered from evidence.

This is not lying in the traditional sense. The physician is not deliberately deceiving. She is confabulating—a term borrowed from neurology describing how the brain fills gaps in memory or knowledge with fabricated content, often without conscious awareness. The confabulator believes what she is saying. That is what makes it so dangerous.

In obstetrics, I have heard colleagues explain with complete certainty why continuous fetal monitoring prevents cerebral palsy (it does not), why episiotomy speeds healing (the opposite is true), why elective induction at 39 weeks lowers cesarean risk for all women (population data show the opposite effect), and why a particular cesarean was “necessary” when the indication was never documented and the tracing was category I.

These are not malicious fabrications. They are the brain’s reflexive response to an intolerable situation: a physician who is supposed to know, standing before a patient who expects her to know, unable to admit that she does not.

Why Physicians Hallucinate

Medical training creates the conditions for confabulation. From the first day of medical school, uncertainty is treated as weakness. The attending asks a question on rounds; the correct response is an answer, not “I don’t know.” The student who says “I’m not sure, let me look it up” is marked as underprepared. The resident who hesitates is told she lacks confidence. The physician who admits ignorance to a patient risks losing trust—or so we are taught.

The result is a profession that systematically selects for and reinforces false certainty. We learn to project confidence independent of actual knowledge. We learn that an authoritative wrong answer is professionally safer than an honest admission of uncertainty. We learn, in short, to hallucinate.

The electronic health record compounds the problem. Documentation demands certainty. Dropdown menus do not include “unclear” or “uncertain.” Billing codes require diagnoses. The system is architecturally hostile to epistemic humility. So physicians document with precision that their actual knowledge does not support, and over time, the documented fiction becomes the remembered reality.

More Dangerous Than Any AI

The hallucinating physician is more dangerous than any hallucinating AI for three reasons.

First, there is no audit trail. When ChatGPT fabricates a citation, you can check PubMed. When a physician fabricates a rationale, the patient has no recourse. She cannot Google her doctor’s confidence. She trusts the white coat. She assumes the certainty reflects knowledge. She makes decisions about her body and her baby based on explanations that were manufactured in the moment.

Second, there are no guardrails. AI companies are building elaborate systems to detect and flag uncertain outputs, to cite sources, to say “I don’t know” when appropriate. Medicine has no equivalent infrastructure. There is no real-time fact-checking of physician statements. There is no uncertainty quantification attached to clinical recommendations. There is only the assumption—increasingly unjustified—that the physician’s confidence correlates with the evidence.

Third, the hallucinating physician cannot be updated. A language model can be retrained, fine-tuned, corrected. A physician who has confabulated an explanation and repeated it for years has converted fabrication into conviction. She now genuinely believes the false explanation. She will teach it to residents. She will defend it against contradicting evidence. The hallucination has become doctrine.

The Obstetric Confabulation Epidemic

Obstetrics is particularly fertile ground for physician hallucination. We practice in a field where the evidence base is sometimes thin, where defensive medicine incentivizes intervention, and where tradition substitutes for data.

Ask an obstetrician why she recommends induction for a patient with an “aging placenta” at 39 weeks and you will receive a confident answer. Ask for the evidence that placentas deteriorate meaningfully between 39 and 40 weeks, and confidence will give way to bluster. The concept of placental senescence driving routine early delivery is a hallucination—widely shared, deeply believed, and largely unsupported by rigorous evidence.

Ask why a patient “needed” a cesarean for failure to progress after six hours of labor, and you will hear explanations about maternal and fetal safety. Ask for the evidence that six hours represents a meaningful threshold, and you will discover the number was invented—a convenient fiction that became policy because someone said it with authority and no one checked.

Ask why continuous electronic fetal monitoring is standard for low-risk patients despite five decades of randomized trials showing no benefit over intermittent auscultation, and you will hear about safety, liability, reassurance. You will not hear an honest answer: we do it because we have always done it, and stopping would require admitting that “always” was never justified.

The Cure for Confabulation

The cure is not technological. It is cultural.

We need to create medical environments where “I don’t know” is not weakness but intellectual honesty. Where “let me look that up” is not incompetence but rigor. Where admitting uncertainty to a patient is not a failure of confidence but an act of respect.

This requires unlearning what training taught us. It requires attending physicians who model uncertainty on rounds rather than punishing it. It requires documentation systems that permit epistemic humility rather than forcing false precision. It requires a professional culture that values being right over sounding right.

Most importantly, it requires remembering that the patient across from us is making irreversible decisions about her body based on what we say. She deserves our honesty more than our confidence. If we do not know, she has a right to know that we do not know. If the evidence is uncertain, she has a right to that uncertainty.

The hallucinating physician believes s/he is protecting the patient from confusion. In reality, she is protecting herself from discomfort, and transferring the cost of that comfort onto someone who trusted her.

Look it up before opening your mouth

We frequently warn about AI “hallucinations,” but we must be equally vigilant about the hallucinations of medical professionals who prioritize anecdote over evidence. Whether counseling a patient or testifying in court regarding fetal tracings, a doctor who relies on intuition or outdated memory rather than verifying current data is acting less than professionally. This type of “System 1” thinking, fast, emotional, and unchecked, creates a dangerous fog of misinformation that can alter patient choices and legal outcomes.

True expertise requires the humility to pause and verify; if you don’t look it up before you speak, you aren’t providing medical opinion, you are simply making things up.

I often told my patient to send in important questions at least 48-72 hours before the visit so I could thoroughly research them and answer them fully evidence-based.

The Mirror Is Coming

AI-empowered patients are coming. They will arrive with citations. They will ask questions we cannot bluff our way through. They will expose every hallucination we have been delivering as fact.

We can treat this as a threat and build better defenses—more sophisticated documentation, more elaborate justifications, more confident confabulation. Or we can treat it as an opportunity to finally become the physicians we should have been all along: honest about what we know, humble about what we do not, and rigorous enough to tell the difference.

Wisdom begins not with answers but with knowing how to ask. The first question every physician should ask, before opening her mouth to answer a patient, is simple: Do I actually know this, or am I about to make it up?

The answer to that question is the beginning of trustworthy medicine.

Have you witnessed—or caught yourself in—medical confabulation? How do we build a culture that rewards intellectual honesty over performed certainty? I welcome your reflections.

Reproductive endocrinology and infertility has a particular relationship with hope that no other subspecialty quite replicates. Patients arrive having already processed loss: miscarriages, failed cycles, diagnoses of diminished ovarian reserve, partner factor infertility, unexplained infertility that is its own particular cruelty. They arrive sophisticated about their own bodies. And they arrive needing something that the AI empathy debate has consistently failed to name correctly.

What they need is not empathy. What they need is compassion.

The distinction between those two words is the argument this post makes, and it matters most in REI because this subspecialty has a unique capacity to confuse one for the other, with real consequences for patients.

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Empathy Is Not Enough

• Empathy is the perception of another person’s emotional state and some resonance with it. It can be trained, and as recent research confirms, it can be convincingly simulated. Patients shown AI chatbot responses to medical questions rated them as more empathic than physician responses. That finding has been replicated across settings.

• Compassion goes further. It is empathy plus the moral commitment to act on what you perceive, including when that action is unwelcome. The compassionate REI clinician does not just recognize her patient’s grief and hope across multiple failed cycles. She is moved by it to do something: to explain, to guide, to stay, and, when the evidence warrants it, to tell her patient honestly that continuing treatment is unlikely to change the outcome. That last act is what communicative empathy cannot perform. It requires a clinician who cares enough about the patient’s whole life to disappoint her.

Bioethicist John Lantos frames the distinction as communicative empathy versus moral empathy. Large language models have mastered the first. What they cannot do is the second: a genuine responsiveness to another person’s suffering that reshapes how you act. In REI, this distinction is not philosophical. It is where clinical harm begins.

— PAYWALL BREAK — Free readers see above. Paid subscribers continue below.

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Every obstetrician has said it. Every mother has heard it. I said it myself, more than once, in fifty years of practice. It took me longer than I would like to admit to understand what the sentence actually does.

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Picture the six-week postpartum visit. On paper, the birth went well. Healthy baby. Stable mother. No complications. The chart is closed and every quality metric is green.

But the woman in the chair wants to talk about something the chart never recorded. The moment her water was broken without anyone asking her. The cervical exam done in the middle of a contraction while she said “wait.” The three strangers who walked into the room during the most exposed moment of her life, and none of them said their name. Lying on the table, hearing her body discussed as if she had already left the room.

She starts to speak. Someone says the sentence. The conversation is over. She is now a grateful mother with a healthy baby, and what happened to her has been filed under “irrelevant.”

She will not file it there. She will carry it into her next pregnancy, if she allows herself a next pregnancy at all.

Where the Sentence Came From

The sentence began as something honest. It is worth remembering how honest.

At the start of the twentieth century, six to nine American women died of pregnancy complications for every 1,000 live births. About 100 babies out of every 1,000 died before their first birthday. Those are CDC numbers, and they describe a world most of us can no longer imagine. A family with five children expected to lose at least one. A pregnant woman knew women who had died giving birth, sometimes in her own family.

By 1997, maternal mortality had fallen almost 99 percent, to fewer than 8 deaths per 100,000 live births. That decline is one of the great achievements in the history of medicine. When my career began, the memory of the old numbers was still alive in the delivery room. “A healthy baby” was not a platitude then. It was a genuine triumph, and everyone knew it.

But obstetrics kept the sentence after the circumstances changed. In a country where the overwhelming majority of births now end with a living mother and a living baby, the sentence no longer describes a triumph. It performs a function. It closes a conversation the clinician does not want to have. What began as gratitude became a shield. And a shield, held long enough, becomes a way of not looking.

What Counts as an Outcome

Before we go further, we should define the word, because the whole argument lives inside it.

An outcome is anything a person carries out of an encounter with medical care. In obstetrics, we measure the outcomes we can count: deaths, hemorrhage, infection, Apgar scores, NICU admissions, cesarean rates.

These matter enormously. They are the floor of good care, and I have spent a career defending that floor. Nothing in this post argues otherwise.

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But the floor is not the ceiling. Every birth also produces a second set of outcomes that never appear in the chart. Was the woman told what was about to happen to her body before it happened? Were her questions answered? Were her refusals respected? Was she treated as the central person in the room, or as the surface on which obstetrics was performed?

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The World Health Organization made this explicit in 2018. Its intrapartum care recommendations named a “positive childbirth experience” as a real goal of maternity care, standing next to safety, not beneath it.

This was not sentimentality from Geneva. It was a recognition that safety and experience happen in the same room, delivered by the same people, at the same time.

Women remember these outcomes for decades. Ask any woman over seventy about her births. She will not tell you her estimated blood loss. She will tell you who was kind to her and who was not, often with the name of the nurse attached. Memory is the outcome measure with the longest follow-up in our specialty, and we have never once audited it.

What the Numbers Show

This is not sentiment. It is data, and the data are recent and American.

In 2023, the CDC published a Vital Signs report on maternity care experiences, based on a survey of more than 2,400 women who had given birth. About one in five reported at least one form of mistreatment during their maternity care. The survey asked about specific behaviors: being shouted at or scolded, being ignored, having requests for help refused or left unanswered, having physical privacy violated, being threatened with withholding of treatment. These are not vague complaints about bedside manner. They are concrete acts, reported by mothers, in American hospitals, in this decade.

Nearly three in ten women in the same survey reported discrimination during their care, based on age, weight, income, or race and ethnicity. Rates of mistreatment were higher for Black, Hispanic, and multiracial women. They were also higher for women with no insurance or public insurance.

That last finding deserves a paragraph of its own, because it points at the structure rather than at individuals. Mistreatment tracks payer status. The women our system pays the least for are the women our system respects the least. I have written before that insurance, not race alone, is the primary structural driver of American maternal outcome disparities. Medicaid pays roughly half of what private insurance pays for the same birth, and the consequences reach every corner of care. The mistreatment data fit that pattern precisely.

The CDC report did not appear out of nowhere. The Giving Voice to Mothers study, published in 2019, surveyed more than 2,100 American women and found that about one in six reported mistreatment. The pattern by race was stark: about 23 in every 100 Black women reported mistreatment, compared with about 14 in every 100 White women. And one finding in that study should stop every clinician cold. Mistreatment rates rose sharply when unexpected interventions occurred, when labor deviated from the plan.

Read that carefully. The moments when a woman most needs to be informed and included, the moments when things change quickly, are exactly the moments when she is most likely to be silenced. We treat the unexpected as a license to stop explaining. It should be the trigger to explain more.

What Happens After

A birth experience does not end at discharge. It has a natural history, and we have measured it.

A large meta-analysis of 59 studies covering more than 24,000 women found that about 4 in every 100 women in community samples meet criteria for post-traumatic stress disorder after birth. In high-risk groups, such as women with complicated or frightening deliveries, the rate was close to 19 in every 100. To put that in perspective: in a hospital doing 3,000 deliveries a year, a 4 percent rate means roughly 120 women each year leaving with a diagnosable trauma response to their own birth. Not sadness. Not the “baby blues.” Post-traumatic stress.

The downstream effects are documented across this literature: postpartum depression, damaged early bonding, avoidance of medical care, fear of future childbirth, and decisions against future pregnancies. A woman who leaves the hospital physically intact but afraid to ever return has not had a good outcome. She has had half of one, and the half we ignored will shape her health, and her family, for years.

Notice what connects the trauma literature to the mistreatment literature. It is rarely the emergency itself that women describe as traumatic. It is the experience of losing all voice and control while the emergency happened. The cesarean is not the wound that lasts. Being treated as furniture during the cesarean is.

This Is About Informed Consent, Not Customer Service

Hospitals sometimes respond to this evidence with amenities. Nicer rooms. Better food. A satisfaction survey at discharge with a smiling logo. That response misses the point so completely that it almost proves the point.

Women in these surveys were not reporting bad food. They were reporting that things were done to their bodies without their knowledge or against their stated wishes. That is not a hospitality failure. That is an informed consent failure, and informed consent is not a courtesy. It is the ethical foundation of everything we do.

Informed consent is not a signature collected at admission. It is a continuous conversation that runs through the whole labor: this is what I recommend, this is why, this is what happens if we wait, what questions do you have. The conversation does not pause when labor becomes complicated. Frank Chervenak and I have argued for decades that the ethical work of obstetrics should be done before the crisis, not during it. That is the entire idea of preventive ethics. A woman who has been informed, heard, and included from the beginning almost never becomes the woman in conflict with her team at the moment of decision. Most conflict on labor floors does not come from women refusing good care. It comes from women who were never told what was happening until it was already happening.

And to be clear about what I am not saying: respecting a woman’s voice does not mean abandoning her to a menu of options. The physician’s duty is to recommend, plainly and with reasons, not to hide behind “it’s your choice” when the evidence clearly favors one course. Being heard and being guided are not opposites. A woman can be told directly what her doctor recommends and why, and still be the author of what happens to her body. In fact, that combination is exactly what most women say they want.

Here is the part that should embarrass our profession: respect costs nothing. It needs no randomized trial, no capital budget, no new device, no committee. Ask permission before every exam, every time. Introduce every person who enters the room. Narrate what is happening while it happens, in plain words. When something unexpected occurs, debrief before discharge: sit down, explain what happened and why, and answer questions. And at the postpartum visit, replace the closing sentence with an opening one: “Tell me about your birth.” Then say nothing and listen. We have managed far harder things than this.

Measure It, or It Will Not Change

There is one more step, and it is the one hospitals resist. In medicine, what is not measured is treated as if it does not exist. We count hemorrhage because we decided hemorrhage counts. We do not count whether women were asked before their membranes were ruptured, so in the official record of American obstetrics, that question does not exist.

The instruments exist. Validated measures of respectful care and patient autonomy in childbirth have been published and used in research for years. A labor unit that can report its rate of postpartum hemorrhage to the decimal can also ask every mother, before discharge, whether she was informed before procedures and whether her requests were answered. If the answers embarrass us, that is not an argument against asking. That is the argument for asking.

My Take

Safety comes first. It should, always. I spent fifty years and more than ten thousand deliveries on exactly that, and I will not romanticize birth into a wellness experience where outcomes take a back seat to ambiance. When safety and preference truly conflict, safety wins, and the physician’s job is to say so clearly.

But here is what fifty years taught me: safety and respect almost never conflict. That is the false choice hiding inside the old sentence. The same conversation that makes a woman feel respected is the conversation that makes her care safer, because an informed patient and an informed team make better decisions together, especially when things go wrong.

A healthy baby is the beginning of a good outcome, not the definition of one. The woman is not the packaging the baby arrived in. She is our patient. How she was treated is part of what we delivered, whether or not we ever measured it.

“At least you have a healthy baby” is not reassurance. It is a door closing. The better sentence takes four words longer: “Tell me what happened.”

Bottom Line

One in five American women reports mistreatment during maternity care, and the profession’s standard reply is a sentence designed to end the conversation. Start asking the other question instead. If you want the evidence behind women’s health delivered straight, without the shield, subscribe to ObGyn Intelligence at obmd.com.

References

1. Mohamoud YA, Cassidy E, Fuchs E, Womack LS, Romero L, Kipling L, et al. Vital Signs: Maternity Care Experiences – United States, April 2023. MMWR Morb Mortal Wkly Rep. 2023;72(35):961-967. doi:10.15585/mmwr.mm7235e1

2. Vedam S, Stoll K, Taiwo TK, Rubashkin N, Cheyney M, Strauss N, et al. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health. 2019;16(1):77. doi:10.1186/s12978-019-0729-2

3. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.

4. Centers for Disease Control and Prevention. Achievements in public health, 1900-1999: healthier mothers and babies. MMWR Morb Mortal Wkly Rep. 1999;48(38):849-858.

5. Yildiz PD, Ayers S, Phillips L. The prevalence of posttraumatic stress disorder in pregnancy and after birth: a systematic review and meta-analysis. J Affect Disord. 2017;208:634-645. doi:10.1016/j.jad.2016.10.009

A parasite spread by raw berries and greens has now sickened more than 400 people across 18 states — and the standard cure is a drug we handle with care in pregnancy. Here is the bind, and what it means before, during, and after a pregnancy.

Right now, a microscopic parasite is moving through the American produce supply. As of early July 2026, the CDC has tracked more than 400 cases of an illness called cyclosporiasis across 18 states. Michigan alone, which usually sees about 50 cases in an entire year, has reported close to 600 in a matter of weeks. Twenty people have been hospitalized. So far, no one has died.

This illness does not spread the way a stomach flu does. You cannot catch it from a sick coworker. You catch it from food — most often raw berries, basil, cilantro, snow peas, or leafy greens that were grown or rinsed with water contaminated by human waste. Federal investigators have not yet named a single source, and they may never find just one.

For most healthy adults, this is a miserable week or two and then it is over. For a woman who is trying to conceive, is pregnant, or has just delivered, the calculation is different. Let me explain why.

What Cyclospora actually is

Cyclospora cayetanensis is a single-celled parasite too small to see. It settles in the small intestine and causes watery, often explosive diarrhea, along with cramping, nausea, low appetite, fatigue, and sometimes a low fever. The tiredness can outlast the diarrhea by weeks.

Two features make it stubborn. First, it is not infectious the moment it lands on a strawberry. It needs days to weeks in the environment to mature. That is why one person almost never passes it to another, and why an outbreak can smolder for weeks before anyone connects the dots. Second, it shrugs off the chlorine washes used on commercial produce. Rinsing your berries at home helps a little, but it does not reliably remove the parasite once it is there. And a routine stool test will miss it — the lab has to be told to look for it specifically.

Untreated, the illness can last a few days or drag on for more than a month, fading and then coming back. The treatment of choice is a common antibiotic combination: trimethoprim-sulfamethoxazole, sold as Bactrim, Septra, or Cotrim. One double-strength tablet twice a day for seven to ten days usually clears it. If you are allergic to sulfa drugs, there is no good backup. That single fact is the root of the problem for pregnancy.

How to lower your risk

Start with the honest part: you cannot fully wash this away.

Cyclospora clings to the crevices of berries and herbs, and it shrugs off the chlorine rinses used on commercial produce.

So the single most repeated tip — rinse your fruits and vegetables under running water — helps a little, but it is not a shield. If the parasite arrived on the food before it reached your kitchen, washing will not reliably remove it.

What does work is heat. Cooking reliably kills Cyclospora. The catch is that the foods most often blamed — raspberries and other berries, basil, cilantro, parsley, snow peas, mesclun and other mixed greens — are the ones we almost always eat raw. That is the whole problem in one sentence.

So this summer, the practical move is to think in tiers.

Cooked produce is safe.

Raw produce you peel yourself, like a banana or an orange, is low risk.

The higher-risk items are the raw berries, fresh herbs, and pre-packaged salad greens tied to past outbreaks. You do not have to swear them off, but during an active surge it is reasonable to cook them, buy them from a source you trust, or simply eat fewer of them for a few weeks.

The rest is basic kitchen hygiene that reduces many foodborne illnesses at once: wash your hands with soap before and after handling food, and clean cutting boards, counters, and knives so raw ingredients do not contaminate ready-to-eat ones. Watch for recalls and public health alerts, and if a specific food is named, throw it out rather than washing it and hoping.

One reassurance: because the parasite has to spend days maturing in the environment before it can infect anyone, you cannot catch it from a sick family member. It comes from the food, not the person.

Preconception

Here is the trap. A woman who is trying to conceive gets sick in, say, the third week of her cycle. She does not yet know she is pregnant. The drug that cures her, trimethoprim-sulfamethoxazole, blocks folic acid — the very vitamin we spend years telling women to take before conception to prevent neural tube defects like spina bifida. The neural tube closes about 28 days after the last period, often before a woman has even missed one. Giving a folate-blocking antibiotic during exactly that window is the last thing we want to do.

This does not mean a woman planning a pregnancy should panic over a salad. It means that if she gets a prolonged diarrheal illness this summer, she should tell whoever treats her that she could be pregnant, so the drug choice is made with eyes open. Staying on her folic acid supplement matters more now, not less.

Pregnancy

For a pregnant woman, the parasite itself is not the main danger. Cyclospora lives in the gut. It is not known to cross the placenta or infect the baby directly, the way some other parasites do. The real threats are indirect, and they are serious.

The first is dehydration. Days or weeks of heavy diarrhea drain fluid and salts. In pregnancy, low fluid volume can reduce blood flow to the placenta and can set off early contractions. A well woman can ride out a stomach bug on the couch. A pregnant woman losing fluid for a month is a different situation, and one that can land her in a hospital on IV fluids.

The second is the treatment bind. In the first trimester, we avoid trimethoprim-sulfamethoxazole when we can, because of the folate-blocking risk to the developing brain and spine and reported links to heart defects. Near the end of pregnancy, the sulfa half of the drug raises a separate concern: it can displace bilirubin in the newborn and raise the risk of jaundice and, rarely, brain injury from it. So the one reliable cure sits in a yellow zone at both ends of pregnancy. This is a genuine judgment call — weighing a prolonged, draining illness against a drug we would rather not use. It is not a decision to make from a website. It belongs in a conversation between a woman and her obstetrician.

Postpartum

A new mother is already running on empty — sleep-deprived, healing, often breastfeeding. A month of explosive diarrhea on top of that is not a minor inconvenience. Dehydration can cut into milk supply at the very moment supply is being established.

The good news is that treatment is usually simpler here. Trimethoprim-sulfamethoxazole is generally considered compatible with breastfeeding a healthy, full-term baby once the newborn period has passed. The exceptions matter: it should be avoided while nursing a premature, jaundiced, ill, or stressed infant, or one with G6PD deficiency, because of that same bilirubin concern. For most healthy nursing pairs a few weeks out, the mother can be treated and keep breastfeeding.

Conclusion

The headlines are about salad, and they should be. Wash your produce, understand that washing is not a force field, and pay attention to recalls. But the story underneath the story is about a specific vulnerability. The disease is usually mild. The cure is usually easy. The problem is that “usually” does not describe the woman who is newly pregnant, or trying to be, or just delivered. For her, both the illness and its treatment carry a cost, and the right move depends on exactly where she stands in that arc.

If you are pregnant or planning to be and you develop diarrhea this summer that will not quit, do not wait it out in silence. Get tested — and make sure whoever treats you knows your reproductive status before the prescription is written. The parasite is small. The decision is not.

Bottom line: a mild parasite turns into a real clinical problem the moment pregnancy enters the picture, because the standard cure is a drug we handle with care in pregnancy. If this kind of plain, honest analysis is useful to you, subscribe to ObGyn Intelligence. The evidence should travel.

References

1. Centers for Disease Control and Prevention. Clinical Care of Cyclosporiasis. Atlanta: CDC; 2024. Available from: https://www.cdc.gov/cyclosporiasis/hcp/clinical-care/index.html

2. Centers for Disease Control and Prevention. About Cyclosporiasis. Atlanta: CDC; 2024. Available from: https://www.cdc.gov/cyclosporiasis/about/index.html

3. Centers for Disease Control and Prevention. Domestically Acquired Cyclosporiasis Surveillance, 2026. Atlanta: CDC; 2026. Available from: https://www.cdc.gov/cyclosporiasis/outbreaks/ [case counts as of early July 2026; state totals per Michigan Department of Health and Human Services].

What AI Got Right About Us — And What It Cannot Be

A patient in active labor at 38 weeks asked her nurse why the fetal heart rate was doing what it was doing. The nurse had three other patients. The answer she gave was accurate, brief, and insufficient. The patient remembered it for years.

That gap is real. It predates AI by decades. A 2023 study in JAMA Internal Medicine made it measurable: patients shown physician responses and AI chatbot responses to medical questions rated the chatbot as more empathic. The finding has since been replicated in oncology and patient portal research. [1]

The reflexive response in medicine is to treat that finding as a problem of tone, of training, of communication skills. I want to argue that we are solving for the wrong thing. Empathy is not what obstetric patients need most. Compassion is. And those are not the same word for the same concept.

Compassion and Empathy Are Not Synonyms

• Empathy is the capacity to perceive and resonate with another person’s emotional state. It is cognitive and affective: you recognize what someone is feeling, and you feel some version of it yourself. It is also, as it turns out, learnable by a machine. An LLM trained on millions of human conversations can produce empathic-sounding language with impressive reliability. It has learned the form.

• Compassion goes further. It is empathy plus the motivation to act and the act itself. The word comes from the Latin: to suffer with. A compassionate clinician does not just recognize that her patient is frightened; she is moved by that recognition to do something about it. She explains. She stays an extra two minutes. She calls back. She changes her language because this particular patient, in this particular moment, needs a different kind of communication. Compassion is a moral act, not a communicative one.

You can score high on an empathy scale and be a compassionless clinician. You can sound warm and still be absent. Patients know the difference, even when they cannot name it. Birth experiences are recalled with unusual fidelity for years. The nurse who gave the accurate, brief, insufficient answer was not cruel. She was stretched beyond the conditions that allow compassion to function.

What the Study Actually Measured

Bioethicist John Lantos argues that most empathy scales capture communicative empathy: warm tone, verbal acknowledgment, scripted validation. Those are real things. They matter. They are also reproducible by a language model. What the scales do not capture is what philosopher and psychiatrist Jodi Halpern calls emotional reasoning: a disciplined, medically-informed attunement to what illness means in a specific patient’s life. [2, 3]

The JAMA study measured patients’ perceptions of responses to written medical questions. That is a useful measurement. It is not the same as what happens when a woman has been laboring for 22 hours, her epidural is wearing off, and the team is discussing whether to proceed to cesarean. In that room, what the patient experiences as compassion is inseparable from whether she trusts the clinician’s judgment, whether that clinician knows her history, and whether the clinician is genuinely present or performing presence.

There is also a structural problem the AI finding actually reveals. Lantos notes that medical training systematically erodes empathy, with the sharpest decline in the third year of medical school. The hidden curriculum rewards detachment. Evaluation systems measure diagnostic accuracy and procedural competence. The environment extinguishes what the curriculum claims to cultivate. If a chatbot outscores residents on empathy metrics, the finding tells us something about what residency does to residents. It tells us nothing about whether the chatbot can be compassionate.

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A patient asked me last month how she could keep her baby from being autistic. She had read the headlines. She was scared. She deserved a straight answer, so here it is.

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First, what autism is. Autism spectrum disorder is a difference in how the brain develops. It shapes how a person communicates, connects with others, and takes in the world. It is not a disease caught during pregnancy. It is not an injury. It is a wide spectrum. Some autistic people need lifelong support. Others live fully independent lives and would not trade the way their minds work.

The numbers have climbed fast. In 2000, about 1 in 150 American children were identified with autism by age 8. By 2016 it was 1 in 54. The newest count from the CDC is 1 in 31. That looks like an epidemic. Most of it is not.

Much of the rise comes from better counting. The definition of autism widened over the years. Awareness grew. Doctors began screening earlier and catching milder cases they once missed. Children who used to be labeled something else, or nothing at all, now get a diagnosis. The sharpest recent increases are among Black, Hispanic, and Asian children and in poorer neighborhoods, exactly the groups who were underdiagnosed for decades. That is not a toxin spreading through the population. That is a system finally looking.

So is it the environment? The food? A shot? A pill? This is where the evidence gets clear, and where it collides with the headlines.

Autism is mostly genetic. Studies of twins and of large families all point the same way: somewhere between 60 and 90 percent of the risk is inherited. When one identical twin is autistic, the other very often is too. This is the single most important fact about autism, and the one most likely to be left out of a news segment. For most families, the odds are set in part before the pregnancy even begins. That is not a mother’s fault, and it is not something a diet can undo.

In September 2025, the White House announced that acetaminophen, the drug in Tylenol, taken during pregnancy could cause autism, and urged women to avoid it. The science does not support that claim. The largest and best study followed nearly 2.5 million children in Sweden. Researchers compared siblings: the same mother, the same genes, one pregnancy with acetaminophen and one without. The autism rates were the same. The earlier studies that found a link had not accounted for the reasons a mother takes the drug in the first place, such as fever, pain, and infection, which run in families along with the genes. Acetaminophen remains the safest choice for fever and pain in pregnancy, and every major obstetric society said so within hours.

Here is the part that worries me more. A high fever in pregnancy is itself linked to autism. In one large study, a fever in the second trimester raised the odds by about 40 percent, and three or more fevers after the twelfth week tripled them. Telling a pregnant woman to tough out a fever instead of treating it gets the risk exactly backward.

So what can a woman actually do? Less than the headlines promise, but not nothing.

The one step with real evidence behind it is folic acid, and the timing is everything. In a study of more than 85,000 Norwegian children, women who took folic acid from about four weeks before conception through the first weeks of pregnancy had roughly 40 percent lower odds of autistic disorder, about 1 in 1,000 instead of 2 in 1,000. The protection showed up only when the supplement started before the pregnancy test turned positive. This is the same vitamin already recommended to prevent spina bifida, a birth defect of the spine, which is why I tell every patient planning a pregnancy to start it early.

A few other things shift the odds a little. Treating fevers and infections rather than ignoring them. Reaching a healthy weight and getting blood sugar under control before pregnancy, since obesity and diabetes each raise the risk. Avoiding the seizure medicine valproate when another option exists, because it is one of the few exposures with a clear causal link to autism. Not smoking. None of these are magic. They move a small amount of risk that sits on top of a baseline that is mostly genetic.

And the things being sold as prevention or cure, such as skipping vaccines, avoiding Tylenol, or the drug leucovorin, do not prevent autism. They pull attention away from the one supplement that has data.

My take. The question itself does a quiet harm. It tells mothers that autism is a mistake they can avoid if only they are careful enough, and that is false. Autism is overwhelmingly genetic, the rise is mostly better detection, and the prenatal choices that move the needle are few and modest. Take folic acid before you conceive. Treat your fevers. Get healthy before pregnancy if you can. Then live your life without the guilt the headlines are selling. The loudest voices on autism prevention right now are pointing at a pill that does nothing while ignoring the vitamin that does something. That tells you who is reading the evidence and who is reading the room.

Bottom line: if you are planning a pregnancy, start folic acid now and treat fevers when they come. Most of what the headlines are shouting about is noise. ObGyn Intelligence is free because the work matters. If you want to support it, a paid subscription keeps it independent.

References

1. Shaw KA, Williams S, Patrick ME, et al. Prevalence and early identification of autism spectrum disorder among children aged 4 and 8 years — Autism and Developmental Disabilities Monitoring Network, 16 sites, United States, 2022. MMWR Surveill Summ. 2025;74(SS-2):1-22. doi:10.15585/mmwr.ss7402a1.

2. Tick B, Bolton P, Happé F, Rutter M, Rijsdijk F. Heritability of autism spectrum disorders: a meta-analysis of twin studies. J Child Psychol Psychiatry. 2016;57(5):585-595. doi:10.1111/jcpp.12499. PMID 26709141.

3. Surén P, Roth C, Bresnahan M, et al. Association between maternal use of folic acid supplements and risk of autism spectrum disorders in children. JAMA. 2013;309(6):570-577. doi:10.1001/jama.2012.155925. PMID 23403681.

4. Ahlqvist VH, Sjöqvist H, Dalman C, et al. Acetaminophen use during pregnancy and children’s risk of autism, ADHD, and intellectual disability. JAMA. 2024;331(14):1205-1214. doi:10.1001/jama.2024.3172. PMID 38592388.

5. Hornig M, Bresnahan MA, Che X, et al. Prenatal fever and autism risk. Mol Psychiatry. 2018;23(3):759-766. doi:10.1038/mp.2017.119. PMID 28607458.

6. Hernández-Díaz S, Straub L, Bateman BT, et al. Risk of autism after prenatal topiramate, valproate, or lamotrigine exposure. N Engl J Med. 2024;390(12):1069-1079. doi:10.1056/NEJMoa2309359. PMID 38507750.

7. American College of Obstetricians and Gynecologists. Acetaminophen use in pregnancy and neurodevelopmental outcomes. Practice Advisory. Washington, DC: ACOG; September 2025.

Reddit is where patients and others go at 2 a.m. when they are scared and do not want to bother anyone. Finding the right posts is not simple -- I monitor dozens of communities, filtering thousands of threads for those that reveal something clinically meaningful: a dangerous myth gaining traction, a gap between patient belief and evidence, or a story that guidelines cannot capture. This series -- ObGyn Intelligence on Reddit -- dissects those posts against the medical literature, because ObGyns who ignore social media are ignoring the most unfiltered window into what our patients think, fear, and do between appointments.

Summary

A first-time mother at 35 weeks woke up one morning and realized she had not felt her baby move. She was not immediately worried. He had been active the night before. She had passed a non-stress test the day prior. She drank cold water, went outside, tried to coax movement through a work meeting. Nothing. So she went to the hospital, still convinced she was being overly cautious.

Within minutes of arriving, a doctor performing an ultrasound called a code OB. The room filled with nurses. Her clothes were pulled off. She barely had time to send a misspelled text to her partner before she was unconscious. Her son had no heartbeat. He was resuscitated for 18 minutes. He was transferred to a children’s hospital for therapeutic hypothermia -- a treatment that cools the brain to limit damage from oxygen loss. The MRI came back clean. He spent 35 days in the NICU and came home healthy.

She wrote about it months later, still processing the trauma, hoping the post would find another mother in time. It has been read thousands of times. In the comments, at least one reader went directly to the emergency room after reading it -- and was found to have a fetal arrhythmia.

Find our Interactive Fetal Movement Tool Here

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

I guarantee that what follows will teach you how to save a live!

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There is a disease that can kill a newborn baby in a matter of hours, and most parents have never heard its name. Even many doctors who do not work in the newborn unit would struggle to explain it. It is called necrotising enterocolitis, or NEC. In the most severe cases, close to half of the babies who get it die. A new review from King’s College London asks a question that should change how all of us think about it: how much of NEC begins before birth?

What NEC actually is

NEC is a sudden, severe inflammation of the bowel. The lining of the intestine becomes injured, loses its blood supply, and parts of it can begin to die. A baby who looked stable can deteriorate within hours, with a swollen belly, blood in the stool, and signs that the whole body is under attack. Some babies need emergency surgery to remove the damaged bowel.

NEC almost always strikes babies who are born too early or too small. The smaller and earlier the baby, the higher the risk. Worldwide, about 7 in every 100 premature babies develop NEC. Among the tiniest babies, those born under 1,000 grams (about 2 pounds 3 ounces), between 5 and 22 in every 100 are affected. Babies born at term with healthy birthweights rarely get it.

The damage does not always end when the baby leaves the hospital. Between 15 and 35 of every 100 babies who develop NEC go on to have intestinal failure, meaning their gut cannot absorb enough nutrition on its own. Up to 45 of every 100 survivors have lasting problems with thinking, movement, or development. This is why NEC frightens the people who care for newborns more than almost any other condition.

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You should ask your doctor to do a thyroid blood screen when considering pregnancy and at the first prenatal visit

During the first trimester, the fetus is entirely dependent on maternal thyroxine (T4) crossing the placenta for neurogenesis and neuronal migration. The fetal thyroid gland does not begin producing its own hormone in clinically significant amounts until 18 to 20 weeks of gestation. This absolute dependence creates a critical, narrow window where maternal thyroid sufficiency dictates foundational fetal development and placental health.

Despite this, the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) continue to recommend against universal screening, favoring a targeted “case-finding” approach based on specific risk factors.

A critical review of the literature reveals why this stance is increasingly viewed as inadequate, resting on flawed trial designs and an under-appreciation of obstetrical morbidity.

The Failure of Targeted Case-Finding

ACOG and RCOG guidelines restrict thyroid-stimulating hormone (TSH) screening to high-risk patients—those with a personal or family history of thyroid disease, Type 1 diabetes, goiter, or recurrent miscarriage.

This approach fails fundamentally in clinical practice:

• Massive Miss Rates: Multiple prospective studies demonstrate that symptom- and risk-based screening misses between 30% and 50% of pregnant women with overt or subclinical hypothyroidism (SCH).

• Confounding Symptoms: The classic clinical markers of hypothyroidism—fatigue, weight gain, constipation, and emotional lability—are ubiquitous in early, normal pregnancies. Relying on clinical presentation to trigger a TSH draw is entirely unreliable.

• Fulfilling Screening Criteria: TSH is universally available, highly sensitive, reliable, and inexpensive. Combined, subclinical and overt thyroid diseases are present in roughly 5–10% of pregnancies. The case-finding strategy artificially suppresses detection when an ideal, low-cost screening tool already exists.

Reproductive Endocrinology and Infertility (REI) specialists routinely test thyroid function

Reproductive Endocrinology and Infertility (REI) specialists routinely test thyroid function—specifically serum Thyroid-Stimulating Hormone (TSH)—as a baseline component of the initial evaluation for virtually all patients presenting with infertility or recurrent pregnancy loss (RPL).

While general obstetricians and gynecologists adhering to ACOG or RCOG guidelines rely on a targeted “case-finding” approach, REIs operate under a different clinical paradigm. The American Society for Reproductive Medicine (ASRM) explicit guidelines classify TSH as a standard diagnostic tool in the female fertility workup.

The routine testing protocol in reproductive endocrinology rests on several distinct clinical rationales:

1. The Lower Preconception Threshold (<2.5 mIU/L)

While a general practitioner or general OB/GYN might view a preconception TSH of 4.0 mIU/L as within the normal reference range, an REI views this as a threshold for intervention.

Evolving data and consensus within reproductive medicine dictate that for women actively attempting to conceive, undergoing controlled ovarian stimulation, or preparing for an embryo transfer, the optimal TSH target is less than 2.5 mIU/L.

Routine screening is the only way to catch and down-titrate patients who fall into this narrow, subclinical window.

2. Safeguarding Assisted Reproductive Technology (ART) Outcomes

Subclinical hypothyroidism (SCH) is highly prevalent in the subfertile population. In the context of expensive, highly controlled treatments like In Vitro Fertilization (IVF) or Intraceutical Insemination (IUI), leaving mild thyroid dysfunction undetected is a major risk factor:

• Implantation Failure: Elevated TSH levels are associated with altered endometrial receptivity and poor embryo implantation rates.

• Ovarian Response: Overt or borderline thyroid dysfunction can subtly alter oocyte quality and the ovarian response to gonadotropins.

3. Hyperprolactinemia and Ovulatory Dysfunction

The reproductive axis is highly sensitive to thyroid status. Elevated Thyrotropin-Releasing Hormone (TRH) in a hypothyroid state directly stimulates lactotrophs in the anterior pituitary, leading to hyperprolactinemia. This, in turn, suppresses GnRH pulsatility, causing luteal phase defects, oligo-ovulation, or anovulation. Screening TSH allows REIs to correct the root ovulatory disturbance before initiating ovulation induction agents.

4. Proactive Autoimmune Assessment

When an REI identifies an elevated TSH, they immediately reflex to testing for Thyroid Peroxidase (TPO) antibodies. Thyroid autoimmunity independently increases the risk of miscarriage and placenta-mediated complications, even when the patient is structurally euthyroid. Identifying these patients early allows the specialist to initiate low-dose levothyroxine treatment or plan for intensive monitoring immediately upon a positive HCG.

Ultimately, because REIs are managing the absolute earliest phases of conception and implantation—where the margin for metabolic error is slimmest—universal baseline thyroid screening has been standard practice in fertility clinics for decades.

The Morbidity of Subclinical Hypothyroidism

Universal screening predominantly uncovers subclinical hypothyroidism (elevated TSH with normal free T4) and isolated hypothyroxinemia. Opponents of universal screening argue that these are asymptomatic, “borderline” abnormalities with no proven benefit for treatment. This perspective ignores a massive body of obstetrical data.

Even in the absence of overt disease, SCH—particularly when combined with thyroid peroxidase antibody (TPOAb) positivity—is associated with profound obstetrical risks:

Levothyroxine (LT4) intervention, especially in TPOAb-positive women with TSH > 2.5 mIU/L, has been shown to reduce these maternal and neonatal complications.

LT4 is inexpensive, exceptionally safe in pregnancy, and easily titrated.

Why ACOG and RCOG Guidelines Are Flawed

The resistance to universal screening by ACOG (a Level A recommendation against it) hinges primarily on the argument that treating SCH does not improve fetal neurocognitive outcomes.

This defense is built almost entirely on two major randomized controlled trials (RCTs): the UK-based CATS (Controlled Antenatal Thyroid Screening) trial and the US-based NICHD trial (Casey et al.).

Both trials concluded that children of mothers treated with LT4 for SCH showed no significant difference in IQ at ages 3 or 5 compared to those receiving a placebo.

However, anchoring clinical guidelines to these trials ignores a glaring methodological fallacy.

1. The Timing Fallacy in Key RCTs

In the CATS trial, treatment with LT4 was initiated at a median of 13.3 weeks of gestation. In the NICHD trial, randomization occurred between 8 and 20 weeks, with a mean gestational age at treatment initiation of 16.7 weeks (subclinical cohort) and 17.8 weeks (hypothyroxinemia cohort).

By the time euthyroidism was achieved in these cohorts, the critical first-trimester window for T4-dependent neurogenesis had already closed. Waiting until the late first or mid-second trimester to initiate LT4 guarantees that the developing fetal brain has already been exposed to suboptimal maternal thyroxine. The trials did not prove that treating SCH is ineffective; they proved that treating it too late offers no neurocognitive rescue.

2. Disregarding Obstetrical Outcomes

By narrowing their focus to the neurocognitive endpoints of fundamentally delayed RCTs, major colleges undervalue the immediate obstetrical benefits of treatment. Even if IQ improvements remain debated due to trial limitations, the proven reduction in miscarriage, preterm birth, and hypertensive disorders of pregnancy offers a compelling, standalone justification for identifying and treating SCH early.

3. The Illusion of “Overtreatment” Harm

Opponents frequently cite the anxiety of false positives and the risks of iatrogenic hyperthyroidism. However, LT4 dosing in pregnancy is standard pharmacology. TSH levels can be easily monitored every 4 weeks to maintain normal free T4 levels without inducing hyperthyroid states. The theoretical risk of transient anxiety from a blood draw is vastly outweighed by the morbidity of a preventable preterm birth or placental abruption.

Because targeted screening fails to identify half of the affected population, and given the high safety profile of TSH screening and early LT4 therapy, several national endocrine and obstetric societies (such as those in Spain, China, and Poland) have already abandoned case-finding in favor of universal screening.

A basic thyroid screening test is remarkably inexpensive, which is one of the strongest arguments for its universal adoption. If a patient pays completely out of pocket using direct-to-consumer options or commercial laboratory networks (like Labcorp or Quest Diagnostics), the cost ranges from $20 to $50 for the baseline screening marker.

The price scales depending on how comprehensive the panel is:

The Insurance Landscape

• Under REI Care: Because Reproductive Endocrinology and Infertility specialists order TSH as a standard diagnostic component of a fertility evaluation, it is routinely billed under diagnostic codes that major insurers cover, usually leaving the patient with just a standard copay ($0 to $20) or applying it to a deductible.

• Under General OB/GYN Care: If an obstetrician orders the test as a “routine screen” in early pregnancy without an documented risk factor, insurers adhering strictly to ACOG guidelines may occasionally deny coverage or pass the cost to the patient, citing a lack of medical necessity.

From a public health and health economics perspective, a $20–$50 baseline test is exceptionally low-cost.

When weighed against the massive financial and emotional costs of managing a preventable miscarriage, a preterm birth, or preeclampsia, the economic argument against universal first-trimester screening entirely falls apart.

She had had enough, more recently, of a case settled last quarter for fifty million dollars. The agenda noted the case in small italic type as Item 1(a). It did not name it.

There were eleven of us in the room. Six obstetricians, one of whom was the Chair, and five of whom were not. Two neonatologists. One ethicist. One quality officer. And a representative from Risk, who said nothing for the entire meeting but took copious notes.

Before the draft policy was proposed, the quality officer asked whether the committee should not first review the case that had occasioned the meeting.

The Chair of Obstetrics nodded.

The quality officer read aloud from a single sheet of paper.

A twenty-seven-year-old patient had presented to Labor and Delivery with ruptured membranes. Her last menstrual period placed her at twenty-one weeks and four days. She had not had a first-trimester ultrasound. Her cervix was dilated. Fetal heart tones were present. The obstetric attending documented previable preterm rupture of membranes. A comfort-care conversation was held with the patient by the obstetrician. Neonatology was not called.

Antenatal corticosteroids were not given, because the pregnancy had been deemed previable.

Magnesium for neuroprotection was not given, for the same reason. Thirty minutes later, the patient delivered a vigorous, crying infant weighing five hundred and twenty grams — too large for twenty-one weeks, consistent with twenty-three.

Neonatology was paged emergently.

They arrived thirty minutes after the delivery. In the interval, the infant received no surfactant, no intubation, and no thermoregulation beyond a hospital towel. Resuscitation was eventually performed. Cranial ultrasound on day two showed Grade IV intraventricular hemorrhage. The infant survived, with profound neurologic injury. The case was settled, last quarter, for fifty million dollars.

The quality officer set down the paper.

The room was silent.

The senior obstetric attending spoke first. I have known him for thirty years. He is a careful man. He stitches well. He thanked the quality officer for the review. He said it was a sobering reminder. He observed, however, that the case at issue was, properly understood, a dating discrepancy. The patient had been assigned the wrong gestational age at presentation. Better dating, in his view, would have prevented the outcome. Mandatory neonatology involvement, in his view, would not have, because no policy could substitute for accurate dating.

The senior neonatologist agreed. He added that if neonatology were summoned for every case of suspected previable rupture, the service would be paged for cases that were truly twenty-one weeks, twenty weeks, eighteen weeks, all of which would not have benefited from the page.

The case in question was, he said, regrettably an outlier.

The ethicist said the joint statement of ACOG, SMFM, and AAP specifically addressed this. The whole point of joint counseling, she said, was that dating uncertainty was itself an indication for joint counseling. When the obstetrician was not sure of the gestational age — and at twenty-one weeks by LMP without a first-trimester ultrasound, no one was sure — the case fell precisely within the gray zone where neonatology’s involvement was supposed to ensure the question of viability was not adjudicated by one tired physician at three in the morning.

The senior obstetric attending said this was an interesting interpretation of the joint statement.

The senior neonatologist said it was an aspirational reading.

The representative from Risk took a note.

The quality officer looked at the Chair of Obstetrics. The Chair of Obstetrics looked at her hands.

We proceeded to the draft policy. It read, in its entirety: A neonatologist shall counsel every patient at risk for periviable delivery, and shall be present at every delivery after twenty weeks gestation in which resuscitation may be required. The neonatologists read it carefully. The five other obstetricians read it more carefully than I had expected.

The senior neonatologist had concerns. He had a concern about every. He had a concern about counsel. He had a concern about twenty weeks. He had concerns, in fact, about most of the substantive nouns and all of the modal verbs.

The Chair of Obstetrics said no to each in turn.

It was then that the senior obstetric attending raised his hand a second time.

He wished to register a concern of his own.

The proposal, while admirable in spirit, presented a clinical risk no one had mentioned. The risk, he explained, was this: if a neonatologist were summoned to every periviable case, the family would believe resuscitation was the expected course.

The mere presence of a neonatologist at the bedside, in his view, conveyed an intention to intervene. To call neonatology was, in effect, to commit to active management. He had seen this happen many times. He did not wish to be forced into intervention by the geography of who was standing in the room.

I waited for the ethicist to correct him.

She did. The whole point of involving neonatology, she said, was the opposite.

Joint counseling exists precisely so the family hears, from the team that would manage the neonate, what active resuscitation entails, what comfort care entails, and which paths are available given the gestational age and circumstances. To exclude neonatology from the counseling is to deprive the family of the conversation in which non-intervention is an honest option. Without that conversation, comfort care is not a choice the family makes. It is a default the obstetrician issues alone in the corridor.

The senior obstetric attending said this was, in theory, correct. The difficulty was that in practice, once a neonatologist was at the bedside, the family interpreted presence as commitment. He had watched it happen. He had charts.

The senior neonatologist nodded slowly. He said this was, in fact, a concern he had not raised but should have. He thanked the senior obstetric attending for raising it.

The Chair of Obstetrics looked at the floor for a moment.

The two senior attendings — one from each service — proceeded to develop the concern in collaboration.

The senior obstetric attending observed that flexibility was, in his view, the soul of good clinical practice. The senior neonatologist observed that flexibility was, in his view, exactly what the joint statement had intended when it used the word recommend instead of require.

Together they observed that a policy phrased too rigidly would harm patients by removing the discretion necessary to serve them well.

The ethicist asked which patients.

The senior obstetric attending said: future patients, in aggregate.

The quality officer asked whether the case he had just read aloud counted as a past patient.

The senior obstetric attending said the past patient had been a dating discrepancy.

The representative from Risk took a note.

We tried again. The Chair of Obstetrics proposed: A neonatologist shall be available for consultation in any case of anticipated periviable delivery. The senior obstetric attending and the senior neonatologist each had a concern about the word available. They had the same concern. They expressed it almost in unison, which was, I will admit, the most collaborative moment of the morning.

We tried again. A neonatologist shall be reachable. They had a concern about by whom.

We tried again. A neonatologist shall be reachable by the obstetric team in any case of anticipated periviable delivery.

They had a concern about anticipated.

Anticipated, they observed jointly, was a clinical judgment. Clinical judgment varied.

The Chair of Obstetrics said quietly that this was, in fact, the problem the policy had been written to solve. The quality officer said this was, in fact, the problem fifty million dollars had failed to solve.

We broke for lunch.

After lunch, the senior obstetric attending and the senior neonatologist returned together. They had drafted a final compromise during the break. It read: Neonatology and Obstetrics shall maintain ongoing collaborative dialogue regarding patients at risk for periviable delivery, in keeping with national professional guidelines and institutional resources, and shall jointly determine the appropriate level of involvement on a case-by-case basis.

It was, they said, comprehensive.

It was, the Chair of Obstetrics agreed, comprehensive.

It was unanimously adopted. The five obstetricians who were not the Chair voted yes. The two neonatologists voted yes. The quality officer voted no, audibly. The ethicist abstained. The representative from Risk took a note.

On my way out, I passed the senior obstetric attending and the senior neonatologist getting coffee in the corridor. They were laughing at something. I do not know what.

I asked the Chair of Obstetrics what the policy would change. She said it would change nothing operationally, since shall jointly determine on a case-by-case basis meant each case would continue to be handled the way each case had always been handled, which was that the obstetrician on call would do the counseling alone, deliver the baby, perform the initial resuscitation, and then call neonatology to take over once the airway was secured.

I asked whether the new policy would have changed the outcome of the case the quality officer had read aloud. She said it would not have. Shall jointly determine on a case-by-case basis would have permitted the obstetrician to make the same call, alone, that the obstetrician had made.

I asked whether the next case would be different. She said she did not know.

I asked whether the fifty million dollars had figured into the committee’s deliberations. She said it had been mentioned.

I asked whether it had figured.

She said the fifty million dollars had not been on the agenda. The agenda had been definitions.

The hospital announced, with appropriate solemnity, the formation of the Interdisciplinary Task Force on Sensitive Clinical Encounters.

This was considered a major victory for patient safety because until then the hospital had only protected patients using mission statements, laminated posters, and a mandatory online module titled Respect Starts With You.

The task force met once a month for eighteen months.

There were representatives from Risk Management, Human Resources, Medical Staff Affairs, Patient Experience, Legal Compliance, Diversity Equity and Inclusion, Graduate Medical Education, and one actual physician who accidentally entered the wrong conference room while looking for coffee.

The proposal under discussion was radical:

Should hospitals require trained chaperones during sensitive examinations?

The room fell silent.

Not because anyone opposed patient safety. Everyone supported patient safety. The hospital had issued seventeen press releases proving this. The concern was operational complexity.

“What exactly,” asked Legal, “is the definition of ‘sensitive’?”

Gynecology suggested pelvic exams.

Urology suggested genital exams.

A surgeon suggested rectal exams.

Dermatology became nervous.

Orthopedics quietly removed itself from the discussion entirely.

Risk Management then raised an important point. If the hospital officially required chaperones, and one was not present, plaintiffs’ attorneys might later argue the standard had not been followed.

This was considered dangerous.

It was therefore proposed that chaperones remain “strongly encouraged,” “recommended whenever feasible,” and “left to professional judgment.”

This language was praised for its flexibility, which in hospital administration means everyone is protected except the patient and the clinician standing alone in the room.

The physician in the corner asked whether requiring chaperones might also protect doctors from false accusations.

The committee agreed this was true but warned that making the policy mandatory could imply the hospital believed accusations occasionally occur.

This was considered even more dangerous.

Patient Experience proposed a compromise. Instead of requiring chaperones, the hospital could create a brochure explaining that patients “may request the presence of a support person or trained staff member.”

The brochure was printed on glossy paper at considerable expense.

No one checked whether frightened patients in vulnerable situations actually felt comfortable requesting one.

The professional organizations then entered the discussion. They released a beautifully worded statement affirming dignity, trust, communication, trauma-informed care, equity, compassion, shared decision-making, and the importance of listening.

The word “required” did not appear.

One committee member finally asked the forbidden question.

“If chaperones improve safety, reduce misunderstandings, protect patients, and protect clinicians, why not simply require them?”

The room became tense.

Because medicine loves recommendations. Recommendations are elegant. Recommendations generate consensus statements, webinars, and continuing education credits.

Requirements generate staffing costs. And they create, well, requirements.

And so the hospital reached a courageous compromise.

A mandatory committee was created to discuss why mandatory chaperones should remain optional.

The government dismantles gun violence research. The food industry drives the obesity epidemic. The Medicaid system most OBs refuse. The postpartum period no one monitors. Then we call the deaths preventable.

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Preventable. Except We Are Actively Working Against Prevention.

Overdose, homicide, and suicide now lead US maternal mortality. What the country is actually doing about each one is a story about choosing not to prevent.

Most maternal deaths in the United States happen after a woman leaves the hospital. n Germany, statutory insurance covers postpartum midwife care, often including daily home visits early after birth and, in some descriptions, up to 20 visits in the first 10 days. The Netherlands provides kraamzorg, a maternity care aide/nurse system, usually about 49 hours of in-home support during the first 8 days after birth, adjusted by clinical and family need. The United States sends a six-week appointment letter. Then calls the death preventable. If you want to understand American maternal mortality, start there.

Overdose, homicide, and suicide now account for more than a quarter of US maternal deaths. The government has cut the CDC division that tracks gun violence, canceled $100 million in gun violence prevention grants, and proposed eliminating the CDC maternal health and safety programs entirely. It still calls these deaths preventable. The word “preventable” when spoken by a government actively dismantling prevention is not a health policy. It is a statement of indifference.

Over 700 women die worldwide every day from preventable causes related to pregnancy and childbirth.

The United Nations published that figure in 2025.

The World Health Organization confirms it.

The number is accurate.

The word “preventable” is doing something specific in that sentence. It creates a moral category without naming a responsible actor. In the United States, that missing name is doing a great deal of damage.

A study published in the New England Journal of Medicine in February 2026 analyzed every maternal death in the United States from 2018 to 2023. The leading cause was unintentional drug overdose, at 5.2 deaths per 100,000 live births. The second was violence, meaning homicide and suicide combined, at 3.9 per 100,000. Together, those three causes accounted for more than one quarter of all US maternal deaths, nearly matching the combined total from cardiovascular disease, infection, hypertension, and hemorrhage.1

None of those deaths are primarily an obstetric failure.

They are failures of addiction medicine access, gun legislation, mental health coverage, poverty policy, and food systems. The obstetrician is in the room. The insurer, the legislature, the food industry, and the law enforcement system are not. So the obstetrician absorbs the guilt by proximity, the responsible institutions remain unnamed, and the deaths continue.

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The Postpartum Abandonment

Here is a structural fact about American maternity care that is not in the UN statement. Most US pregnancy-related deaths do not happen during delivery. The majority happen after a woman goes home. CDC data from Maternal Mortality Review Committees show that over half of pregnancy-related deaths occur in the postpartum period, and 39 percent occur between six weeks and one year after delivery, the period when standard US care provides the least contact.2,3

The standard US postpartum protocol for a woman with no identified complications is this: leave the hospital within 24 to 48 hours after a vaginal birth, or 72 to 96 hours after a cesarean. Then nothing, until a single appointment at six weeks. In those six weeks, postpartum depression can escalate to psychosis. Hypertension can worsen toward stroke. Cardiomyopathy can declare itself. A violent partner can become lethal. A substance use disorder can end in overdose. The healthcare system is watching none of it.

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Now consider what other wealthy countries do with the same six-week window.

In Germany, all women are entitled by law to home visits from a midwife: up to 20 visits in the first 10 days after discharge, then up to 16 additional visits until the baby is 12 weeks old.4 In the Netherlands, a qualified maternity nurse, known as a kraamverzorgster, provides in-home care for up to 8 to 10 days after birth, with a standard allocation of 49 hours covered by basic national health insurance.4 In Denmark, a midwife calls the day after discharge and an at-home health visitor arrives within four to five days. In the United Kingdom, every woman receives at least one postnatal home visit from a midwife, with more available based on clinical need.5 In France, one to four home visits are provided, depending on maternal and infant status.5

A 2024 comparative study of six high-income countries found that every country in the analysis except the United States offers universal at-home postnatal visits.5 The United States is the only country in this group that sends women home from the hospital and provides no structured professional contact until six weeks later. The United States also has the highest maternal mortality rate of any high-income country. Calling these deaths preventable while maintaining the only postpartum care system in the developed world that provides no home visits is not a public health position. It is a performance of concern without any of its costs.

The Medicaid Wall

Medicaid covers 41 percent of all births in the United States. It covers 64 percent of births to Black women and nearly 50 percent of all rural births.6 It is the primary payer of maternity care for the women at highest risk. It reimburses at an average of 82 percent of the Medicare rate.7

In South Florida, a cross-sectional study contacted 178 obstetricians and found that 97 to 98 percent accepted major private insurers, while only 45 percent accepted Medicaid.8 That pattern repeats nationally. A coverage program that nominally insures 41 percent of pregnant women but is refused by the majority of specialists in many markets is not a functioning system. It is a designation attached to a care gap. Women with Medicaid on paper, in markets where no OB within a reasonable distance accepts it, receive delayed care or no care. Then their deaths are classified as preventable.

The coverage cliff compounds the problem. Standard pregnancy Medicaid ends 60 days after delivery. One quarter of pregnancy-related deaths occur between six weeks and one year postpartum, the period immediately outside standard coverage.2 The expansion to 12-month postpartum Medicaid coverage, implemented in most states between 2022 and 2024, was an evidence-based correction to an obvious structural failure. Federal budget reconciliation legislation passed in 2025 is now projected to cut Medicaid spending in rural areas alone by an estimated $155 billion over 10 years, accelerating the closure of rural obstetric units that already cite low Medicaid reimbursement as their primary reason for shutting down.6

The Government as Active Counterpreventer

In April 2025, the Department of Health and Human Services eliminated more than 10,000 CDC positions.

The CDC Division of Violence Prevention, which studies gun deaths, domestic violence, suicide, and maternal homicide, lost approximately three quarters of its staff. The White House Office of Gun Violence Prevention was shut down. A Surgeon General advisory on gun violence as a public health emergency was removed from official websites. The National Violent Death Reporting System, which generates the data researchers use to understand homicide and suicide trends during pregnancy, was operationally gutted.9

Since 2019, Congress had restored $25 million per year to the CDC and NIH for gun violence research, ending a 20-year federal ban. In 2025, despite Congress retaining that allocation, neither agency posted a single new grant opportunity for firearms or violence prevention research. The Trace found that more than $100 million in gun violence grants across federal departments was canceled, including programs in cities that had documented historic reductions in gun violence in direct response to those grants. States including South Carolina, Louisiana, and Alabama lost funding alongside blue-state cities.9

The White House proposed a budget cutting the CDC by more than 50 percent, from $9.2 billion to $4.2 billion. Among the programs specifically listed for elimination: maternal health and safety at the CDC. The programs that collect, analyze, and publish the data that tell us how and why pregnant women die would cease to exist under this proposal.10

This is what it looks like when a government calls deaths preventable while systematically removing the infrastructure required to prevent them.

The word “preventable” in a press release does not cost anything. Funding the Violence Prevention Division, maintaining gun violence research grants, keeping rural obstetric units open through adequate Medicaid reimbursement, and building a postpartum home visit infrastructure: those cost something. The United States has chosen, with specificity and consistency, not to pay those costs.

The Obesity Pipeline and the Food Industry

Obesity contributed to approximately 29 percent of all pregnancy-related deaths reviewed by state Maternal Mortality Review Committees.11 In cardiovascular maternal deaths specifically, the most common direct obstetric cause of death in the United States, obesity was identified as a contributing circumstance in nearly half of all cases.12 The cardiovascular risk associated with pregnancy is substantially amplified by obesity, and the trajectory from obesity to hypertensive disorder to cardiomyopathy to maternal death is well documented.

Obesity does not appear from nowhere. It is the predictable output of a food system in which ultra-processed, calorie-dense, nutritionally depleted products are the cheapest and most available option in lower-income communities. Research links high ultra-processed food intake to increased risk of maternal preeclampsia, gestational hypertension, and gestational diabetes.13 A meta-analysis published in 2025 found that the highest quartile of ultra-processed food consumption was associated with a 15 percent increase in all-cause mortality.14 Women consuming the highest share of ultra-processed foods are more likely to be lower-income, less educated, and food-insecure: the same population that Medicaid covers, that the home visit infrastructure does not reach, and that the rural hospital closure trend is leaving without obstetric services.

The industries producing these products are not regulated in proportion to their documented health consequences. They have lobbied against nutrition labeling requirements, against restrictions on marketing to children, and against policies that would make fresh food competitive in price with processed alternatives. The cost of that political success is externalized onto the bodies of low-income pregnant women and onto the maternal mortality statistics that the government then calls preventable.

What “Preventable” Is Actually Doing

The word “preventable” in maternal mortality discourse functions as a morally charged passive construction. It says that a preventable death occurred without saying who failed to prevent it. That ambiguity is not accidental. It allows every responsible actor to read the statistic and feel that the problem belongs to someone standing closer to the patient.

• The insurer who reimburses at rates that drive OBs out of Medicaid: not named.

• The legislature that cut gun violence research: not named.

• The food industry that engineered the obesity crisis: not named.

• The government that proposed eliminating CDC maternal health programs: not named.

• The hospital system that discharges a woman 48 hours after a cesarean section into a country with no home visit structure: not named.

• The six-week gap between discharge and the first postpartum appointment, in the period when most maternal deaths occur: not named.

These are not minor oversights.

They are the mechanism by which a wealthy country sustains one of the highest maternal mortality rates in the developed world while generating advocacy statements about preventable deaths.

My Take

I have practiced obstetrics for 50 years. I have seen what it looks like when a woman dies in the postpartum period from a complication that was predictable, identifiable, and treatable. I have also seen what it looks like when an institution classifies that death as preventable and then changes nothing about the system that produced it.

The United States has a specific, identifiable maternal mortality problem that is not primarily a clinical problem.

It is a postpartum access problem, an insurance coverage problem, a gun policy problem, an addiction medicine access problem, a food system problem, and a government investment problem.

Every one of those problems has a known solution. Every one of those solutions requires political will and public funding.

Every one of them is currently being cut, defunded, or reversed by the federal government that simultaneously calls these deaths preventable.

When Germany sends a midwife to a new mother’s home 20 times in the first 20 days and the United States sends nothing until six weeks, and then classifies the deaths that occur in those six weeks as preventable, the word has stopped describing reality. It has become a way of assigning moral weight to a problem while declining to do anything about it.

I want the word “preventable” retired from general use in maternal mortality statistics unless it comes with a thorough explanation. “Preventable” how and by whom?

Not because the deaths are not preventable: many of them clearly are. But because “preventable” without a named actor, a named intervention, and a named funding source is not a public health position. It is an alibi. Every maternal mortality statement should be required to answer: preventable by whom, with what, funded how, and why is that not happening right now.

Until those questions have answers attached to them, the 700 deaths a day will continue, and the word “preventable” will continue to do exactly what it has always done: sound like accountability while ensuring that none is ever assigned.

Bottom Line

Most US pregnancy-related deaths happen after discharge, in the postpartum period that the US healthcare system has chosen not to monitor. Every high-income peer country except the United States sends a trained professional to the home. Overdose, homicide, and suicide lead US maternal mortality. The government has cut the research programs and community interventions that address each of those causes. The Medicaid system covers 41 percent of births but is refused by most OBs in many markets. Obesity drives nearly half of cardiovascular maternal deaths and is the product of a food system that faces no regulatory accountability for those outcomes. Calling these deaths preventable without naming the actors responsible for preventing them is not a health policy.

It is a description of a choice.

If you believe evidence should carry consequences, a paid subscription to ObGyn Intelligence keeps this analysis going. The evidence is not hard to find. The willingness to name what it shows is.

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References

1. Azad HA, Goin D, Nathan LM, Goffman D, Rajan S, Reddy U, et al. Overdose, homicide, and suicide as causes of maternal death in the United States. N Engl J Med. 2026;394(7):722-3. doi:10.1056/NEJMc2512078

2. Petersen EE, Davis NL, Goodman D, Cox S, Syverson C, Seed K, et al. Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep. 2019;68(18):423-9. doi:10.15585/mmwr.mm6818e1

3. New York City Department of Health and Mental Hygiene. Maternal mortality annual report 2023. New York: NYC DOHMH; 2023. Available from: https://www.nyc.gov/assets/doh/downloads/pdf/data/maternal-mortality-annual-report-2023.pdf

4. Feather Insurance. Pregnancy, childbirth and family planning in Germany. 2025. Available from: https://feather-insurance.com/blog/pregnancy-childbirth-germany

5. Molenaar J, Korstjens I, Hendrix M, de Vries R, Nieuwenhuijze M. Maternal outcomes and pre, syn, and post-partum care in the United States and five high-income countries: an exploratory comparative qualitative study. Health Policy. 2024. doi:10.1016/j.healthpol.2024.105073

6. Daw JR, Kolbe A, White K, Benfer EA. Medicaid cuts threaten pregnancy and postpartum coverage, access to care, and health. Health Aff Forefront. 2025. doi:10.1377/forefront.20251016.231218

7. American College of Obstetricians and Gynecologists. Equitable payment rates for maternity and surgical care [internet]. Washington (DC): ACOG; 2024. Available from: https://www.acog.org/advocacy/policy-priorities/equitable-payment-rates-for-maternity-and-surgical-care

8. Sheridan L, Bhimavarapu A, Roman A, Mehta A, Falk M, Saade G, et al. Accessibility to obstetric care in South Florida based on insurance: a cross-sectional study. Cureus. 2023;15(9):e44730. doi:10.7759/cureus.44730 [VERIFY DOI]

9. The Trace. Trump has slashed federal funding for gun violence prevention. January 2026. Available from: https://www.thetrace.org/2026/01/trump-public-safety-gun-violence-funding/

10. CNN/KFF Health News. Inside the CDC, shooting adds to trauma as workers describe projects, careers in limbo. August 2025. Available from: https://www.cnn.com/2025/08/11/health/cdc-crisis-limbo-kff-health-news

11. Centers for Disease Control and Prevention. Pregnancy-related deaths: data from maternal mortality review committees in 36 US states, 2017-2019. Atlanta (GA): CDC; 2022. Available from: https://archive.cdc.gov/www_cdc_gov/maternal-mortality/php/data-research/mmrc-2017-2019.html

12. Briller J, Trost SL, Busacker A, Joseph NT, Davis NL, Petersen EE, et al. Pregnancy-related mortality due to cardiovascular conditions: maternal mortality review committees in 32 US states, 2017 to 2019. JACC Adv. 2024;3(12):101382. doi:10.1016/j.jacadv.2024.101382

13. Zhang M, et al. Ultra-processed foods and risk of preterm birth and pregnancy complications. [Published 2026; full citation pending VERIFY.]

14. Huang J, Zhou Y, Wang Y, et al. Ultra-processed foods and risk of all-cause mortality: an updated systematic review and dose-response meta-analysis of prospective cohort studies. PMID:40033461. doi:[VERIFY]

She is not being careless.

She is being human.

Two Nobel laureates spent their careers explaining exactly what happened in that room.

Herbert Simon won the Nobel Prize in Economics in 1978 for something that sounds simple but was genuinely radical: proving that human beings cannot make optimal decisions. Not because we are poorly trained, but because the cognitive task of evaluating all available information, weighting it correctly, and choosing the best option exceeds the architecture of the human brain. Simon called this bounded rationality. He coined the term satisficing — a blend of satisfy and suffice — to describe what the brain actually does: it scans a limited set of options, picks one that clears a good-enough threshold, and moves on.

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In a busy labor and delivery unit, a clinician who paused over every assessment to systematically evaluate all alternatives would be clinically useless.

The satisficing brain is the feature, not the bug, that keeps the floor running. Simon understood this. He was not condemning heuristic thinking. He was mapping its limits.

Daniel Kahneman won the Nobel Prize in Economics in 2002 for a related but sharper finding: the mental shortcuts we use are not just limited — they are systematically biased in predictable ways. Anchoring: the first diagnosis encountered shapes every judgment that follows. Availability bias: we overestimate outcomes we can easily recall from recent experience. Overconfidence: after a run of good outcomes, clinicians consistently underestimate risk in the next case. These are not random errors. They are structured, replicable, and invisible to the person making them.

This is not theoretical. The Society for Maternal-Fetal Medicine acknowledged in a 2022 Special Statement that clinical decision-making in obstetrics is routinely affected by cognitive biases that can lead to medical errors.(1)

The rest of this post is for paid subscribers.

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Norovirus does not check your booking history. A placental abruption at sea is the same emergency for a first-time cruiser as for a repeat cruiser. There is no biological mechanism by which prior cruise experience protects a pregnancy. The “first cruise” caveat is hedge language. It is there to soften a recommendation, not to make a medical distinction.

Strip it out and the sentence reads correctly: planning a cruise while you are pregnant is not a good idea. ACOG hedges. The CDC Yellow Book softens. The cruise lines themselves write the warning into their booking terms rather than their marketing. All point in the same direction.

The Cruise Environment Itself

Cruise ships concentrate large populations into shared dining, shared ventilation, shared sanitation, and continuous passenger turnover at ports. The CDC’s Vessel Sanitation Program defines an outbreak as 3 percent or more of passengers or crew on a single voyage reporting gastrointestinal symptoms. By that threshold, the CDC confirmed 16 outbreaks on cruise ships in calendar year 2024, the largest annual count since 2012. (2) Norovirus was the most common pathogen identified.

Norovirus does not cross the placenta. The dehydration it causes is the obstetric problem. Severe dehydration can precipitate uterine contractions, reduced fetal movement, and electrolyte disturbances that are far harder to manage in a ship’s medical center than in a hospital. Influenza and COVID-19 produce the same pattern in respiratory form.

Geography Becomes Treatment

The CDC Yellow Book 2026, published April 2025, is unusually direct on this point. Travel health risks during cruises include “the possibility of delayed care while at sea.” (3,4) In ordinary medicine, that phrase sounds abstract. In obstetrics, it is the entire issue. Pregnancy emergencies do not announce themselves. Preterm labor, placental abruption, severe preeclampsia, hemorrhage, ectopic rupture, and pulmonary embolism develop in hours in women who were completely well that morning.

The peer-reviewed literature now includes a published case report of a young woman whose ruptured ectopic pregnancy was identified by handheld ultrasound at sea, requiring emergent helicopter evacuation to a shoreside operating room. (5) That is the best case scenario for an obstetric emergency on a ship. It depends on weather, on aircraft availability, and on the ship’s medical team correctly identifying the diagnosis. The worst case scenario is a delivery at sea at a gestational age the ship cannot support. The Royal College of Obstetricians and Gynaecologists reaches the same conclusion in calmer prose: the central concern with pregnancy travel is preterm labour or an obstetric emergency developing during the journey. (6)

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The 24-Week Cutoff Is Not a Reassurance

Most cruise lines stop boarding at 24 weeks. This is widely misread as a safety reassurance. It is the opposite. The 24-week threshold reflects the lower bound of neonatal viability with intensive care. The cruise lines stop boarding at 24 weeks because beyond that point a preterm delivery onboard would require a neonatal intensive care unit they cannot provide. The policy is a liability decision, not a medical safety standard.

The medical risks before 24 weeks remain. Miscarriage, ectopic rupture, severe hyperemesis with electrolyte disturbance, venous thromboembolism, and previable preterm labor all occur in the first and second trimesters. ACOG, the CDC, and the RCOG agree that pregnancy emergencies cluster in the first and third trimesters. (1,7,6) The second trimester is statistically the safest, but “safest” is not “safe at sea.”

What This Means for Pregnant Women

The decision to cruise during pregnancy is not really about whether you will have a complication. The probability for any single woman on any single cruise is low. The decision is what happens if you are the woman who does. At home, an unexpected emergency means an ambulance, a hospital, an operating room, and a neonatal team within minutes. On a cruise, the same emergency means a ship infirmary designed for stabilization, a captain making routing decisions, a possible helicopter evacuation, and a foreign hospital that may be hours or a day away. (5,8) The medical center on a ship is not a hospital. It is a stabilization unit with limited diagnostic and surgical capability, not equipped to safely deliver a preterm infant, manage a postpartum hemorrhage, or perform an emergency cesarean.

Insurance is a separate problem most pregnant women do not anticipate. Standard United States health insurance often does not cover medical care delivered onboard a cruise ship or at a foreign hospital. Travel insurance with medical evacuation coverage is essential, but most policies have pregnancy clauses worth reading carefully. A travel insurance policy that excludes complications of pregnancy is not adequate coverage for a pregnant cruiser.

My Take

Patient autonomy is the foundation of obstetric ethics, and autonomy depends on honest counseling. A clinician who avoids telling a pregnant patient the truth about cruise travel because the conversation is uncomfortable is not respecting autonomy. The clinician is undermining it. The professional responsibility model requires recommending the best evidence-based option, not handing a patient a menu and stepping back.

ACOG hedges with “may not be a good idea” and adds an incoherent qualifier about first-time cruisers. The CDC writes about “the possibility of delayed care.” The cruise lines write about gestational viability cutoffs. All are saying the same thing without saying it. I am not in the liability business. A cruise during pregnancy is a low-probability, high-consequence decision. Most cruises will be uneventful. The ones that are not are the reason this advice exists.

Bottom Line

Pregnancy is stable until the moment it is not. When an obstetric complication occurs, minutes and access determine outcome. A cruise ship cannot provide either.

Skip the cruise. Choose a vacation within reach of advanced obstetric and neonatal care. The scenery is not the point. The proximity is.

If this analysis was useful, subscribe to ObGyn Intelligence. Evidence-based, direct, and unhedged.

References

1. American College of Obstetricians and Gynecologists. Travel during pregnancy. ACOG Patient FAQ. Available at: https://www.acog.org/womens-health/faqs/travel-during-pregnancy

2. Centers for Disease Control and Prevention. Outbreaks on cruise ships in VSP’s jurisdiction. Vessel Sanitation Program. Available at: https://www.cdc.gov/vessel-sanitation/cruise-ship-outbreaks/index.html

3. Centers for Disease Control and Prevention. Cruise ship travel. In: Halsey ES, Angelo KM, Barnett ED, et al., editors. CDC Yellow Book 2026: Health Information for International Travel. Atlanta (GA): Centers for Disease Control and Prevention; 2025. Available at: https://www.cdc.gov/yellow-book/hcp/travel-air-sea/cruise-ship-travel.html

4. Galang RR, Roy SC. Pregnant travelers. In: Halsey ES, Angelo KM, Barnett ED, et al., editors. CDC Yellow Book 2026: Health Information for International Travel. Atlanta (GA): Centers for Disease Control and Prevention; 2025. Available at: https://www.cdc.gov/yellow-book/hcp/family-travel/pregnant-travelers.html

5. Boniface KS, Aalam AA, Liu YT, Galagan J, Buisson E, Shokoohi H. A cruise ship emergency medical evacuation triggered by handheld ultrasound findings and directed by tele-ultrasound. Int Marit Health. 2020;71(1):20-23. PMID: 32212147.

6. Royal College of Obstetricians and Gynaecologists. Air travel and pregnancy. Scientific Impact Paper No. 1. London: RCOG; 2013. Available at: https://www.rcog.org.uk/media/jw4jyghl/sip_1.pdf

7. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Air travel during pregnancy. ACOG Committee Opinion No. 746. Obstet Gynecol. 2018;132(2):e64-e66. PMID: 30045212.

8. Hezelgrave NL, Whitty CJM, Shennan AH, Chappell LC. Advising on travel during pregnancy. BMJ. 2011;342:d2506. doi: 10.1136/bmj.d2506.

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Her uterus begins contracting too fast, too hard, and without stopping.

Her baby is starved of oxygen.

The staff is happy because the cervix dilates fast.

The delivery is complicated by shoulder dystocia, the baby’s shoulder lodges behind the mother’s pelvis. Minutes pass. The child is born with brain damage that will define the rest of his life.

Cerebral palsy.

Most of the time cerebral palsy happens before labor, but often it happens during labor.

This sequence, or some version of it, generates the largest malpractice verdicts in American medicine.

It is the story behind the seven consecutive years of rising obstetric liability premiums the American Medical Association reported last week. It is the reason OB-GYNs in Miami-Dade County are paying nearly $244,000 annually for malpractice coverage, and why maternity units are closing across the country.

It is also, in a significant proportion of cases, preventable. We know this because we prevented it. We published exactly how in 2011. Then we watched most of the profession decline to do the same.

The Program

In 2011, we published the results of a comprehensive obstetric patient safety program we had implemented at Weill Cornell Medical Center starting in 2003 in the American Journal of Obstetrics and Gynecology (AJOG: The “Gray Journal”). It was not speculative. It was not a proposal. It was a report of what we had actually done, over six years, at one of New York City’s largest academic labor and delivery units, and what happened to malpractice payments and sentinel adverse events as a result.

What is strange is that liability lawyers hailed our paper. Hospitals disliked it.

The program was not a single intervention. It was a system. Multiple integrated components, each targeting a specific source of preventable harm. The components included:

• Ban on misoprostol for labor induction. Misoprostol had never been approved by the FDA for this indication. Its use was entirely off-label. The clinical evidence — including our own data — showed it was associated with irreversible uterine tachysystole: contractions so frequent and sustained they cut off oxygen to the fetus. Unlike intravenous agents, a dissolved tablet cannot be removed. Once the overstimulation began, it could not reliably be reversed. Patients were not being told any of this. We stopped using it entirely.

• A single, standardized oxytocin protocol. Oxytocin dosing on labor and delivery had been a matter of individual physician preference — every attending doing it differently, often without documentation, often without a ceiling. We implemented one protocol, institution-wide, with defined dose escalation, mandatory monitoring intervals, and required dose reduction or cessation criteria. Opponents predicted this would increase cesarean rates. The opposite happened: our cesarean rate fell from 41.6% in 2004 to 32.7% in 2012.

• Structured communication protocols. The most common feature of obstetric adverse events is not clinical misjudgment in isolation — it is a communication failure. The nurse who cannot reach the attending. The resident who does not escalate. The consultant who was never called. We implemented mandatory communication structures: defined escalation pathways, required read-backs, and documentation of every clinical decision and the person who made it.

• Required specialist consults. Not advisory. Not “consider consultation.” Required, documented, in defined clinical circumstances. If a patient met criteria, the consult happened. This removed the discretionary step where physicians, busy or overconfident, decided on their own that a consultant was unnecessary.

• Mandatory team training and drills. Obstetric emergencies — shoulder dystocia, postpartum hemorrhage, eclampsia, cord prolapse — are low-frequency, high-stakes events. The team that has never practiced managing them together will not perform well under pressure. We required regular simulation drills. Not voluntary. Not optional for attendings with busy schedules. Required.

• Daily safety huddles. Every shift, a brief structured review of the patients on the unit: who is high-risk, what is the plan, who needs to know what. This sounds simple. In a busy academic unit it requires discipline and leadership. It surfaces problems before they become emergencies.

• Standardized shoulder dystocia protocols. Shoulder dystocia is unpredictable. It cannot always be anticipated. But the response to it — who does what, in what order, in what timeframe — can be standardized and drilled until it is automatic. We did this. The HELPERR mnemonic and structured maneuver sequences were required practice, not optional familiarity.

• Additional staffing, reduced work hours, and a dedicated patient safety nurse. Fatigue produces errors. Understaffing produces errors. We added staff and reduced the excessive work hours that were then standard. We appointed a dedicated patient safety nurse whose sole responsibility was surveillance, documentation, and follow-through on safety protocols.

• Electronic medical records with structured documentation. Not just a record system — a system that required complete documentation of clinical decisions, drug administration, fetal monitoring findings, and communication. A record that could not be left incomplete.

• Fully informed consent. Patients were told what drugs were being used, including their regulatory status. Patients were told when a drug was off-label. Patients were told the risks. This was not negotiable and not optional.

What Happened

Malpractice compensation payments fell sharply. Sentinel adverse events — ZERO maternal deaths, less birth asphyxia, less hypoxic-ischemic encephalopathy, less Brachial Plexus injury. They all declined. Cesarean delivery rates went down, not up, refuting the central objection that safety protocols drive surgical delivery. The program worked.

We saved the hospital about $20-30 Million. Everyone’s insurance premium declined.

We published it. We presented it. We made the case that this was replicable at any institution with sufficient leadership and will.

What the Profession Did with It

Most hospitals did not implement it. Most did not come close.

Many doctors did not want to be told what to do.

Misoprostol continues to be used for labor induction at institutions across the country, without FDA approval, without disclosure to patients, and without the informed consent that patients are legally and ethically entitled to receive.

After we left, the hospital implemented misoprostol induction again with forseable results.

Oxytocin protocols remained non-standardized. Individual physician preference continued to govern dosing decisions that directly affect uterine activity and fetal oxygenation. The variation that produces inconsistent outcomes — and inconsistent outcomes are what fill plaintiff attorneys’ case files — was left in place.

Team training remained voluntary at most institutions. Shoulder dystocia drills were conducted where leadership demanded them and skipped where it did not. Communication protocols were adopted partially, inconsistently, or not at all. Safety huddles were implemented in some units and dismissed as an administrative burden in others.

The reasons given were consistent across institutions: cost, time, disruption to workflow, physician autonomy, and the reluctance to acknowledge — by implementing informed consent for off-label drugs — that previous practice had carried undisclosed risks.

These were choices. They were made with full knowledge that a published, evidence-based safety program existed and had demonstrated results.

Now They Want Caps

The AMA reported last week that approximately 40% of medical liability premiums rose from 2024 to 2025 — the seventh consecutive year of increases. In Miami-Dade County, obstetricians are paying nearly $244,000 annually. In New Jersey, approximately $94,600. The AMA’s president has called this a wake-up call and is pressing states without damage caps to enact them.

The financial pressure is real. Maternity unit closures are real. The access problem those closures create is serious and deserves attention.

But the AMA’s analysis does not ask the prior question: what is producing the verdicts that produce the premiums? The largest awards in obstetric malpractice are for neurologically injured children. Juries in those cases hear expert testimony about what the standard of care required and where it was not met. They hear about the oxytocin that was not managed to protocol. The drug that was administered without disclosure of its off-label status. The shoulder dystocia that was managed by a team that had never practiced together. The consult that was never called. The communication that never happened.

The verdict is the end of a story that began years earlier, when the institution decided not to implement a safety program it had been shown how to build.

What Caps Do and Do Not Do

Damage caps may modestly reduce premiums in some markets by making liability exposure more predictable for insurers. The evidence for this effect exists, though it is inconsistent across states and specialty types.

Damage caps do not reduce adverse outcomes. There is no mechanism by which limiting what an injured family can recover changes what happens in the labor room. The child with hypoxic-ischemic encephalopathy is not helped by a cap. The family providing lifetime care for that child absorbs the cost that the cap removes from the institution that produced the harm. This is a transfer of financial burden, not a safety improvement. It should not be presented as one.

My Take

We built the program. We ran it for six years. We published what it contained and what it produced. The components were not exotic: stop using an unapproved drug without informed consent, standardize oxytocin dosing, train your team, hold daily huddles, require your consults, practice your shoulder dystocia drills, communicate in a structure that leaves a record. These are not heroic interventions. They are basic systems, and any institution with leadership willing to require them could have implemented them.

Most chose not to. They chose convenience, autonomy, and the avoidance of the informed consent conversation that would have required acknowledging what patients had not been told. That is not a harsh characterization. It is a description of the choices that were made, documented in the pattern of practice that persisted for fourteen years after we showed a better way.

I have no principled objection to malpractice reform. Runaway verdicts are a real problem. Premium pressures are real. Maternity care access is a genuine crisis.

But before asking the legislature to cap what injured families can recover, the profession should answer this question honestly: did you implement the safety program? Did you ban the non-FDA-approved drug used without consent? Did you standardize your oxytocin protocol? Did you hold the daily huddles? Did you require the drills? Did you train the team?

For most institutions, the honest answer is no. Caps on damages may lower premiums. They will not lower the number of children born with preventable brain injuries. The profession that declined to do the work of prevention has not yet earned the legal protection from its consequences.

Citation: Grunebaum A, Chervenak F, Skupski D. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gynecol. 2011;204(2):97-105. doi:10.1016/j.ajog.2010.11.009. [Author to verify and add co-author citation for 2013 J Perinat Med paper on cesarean reduction.]

Amos Grünebaum, MD, is Professor of Obstetrics and Gynecology at the Zucker School of Medicine at Hofstra/Northwell, and Senior Ethics Consultant at Northwell Health. He publishes at obmd.com.

A new publication highlights a growing gap between what we know about heat exposure in pregnancy and what public health systems actually tell pregnant women.

The authors review mounting evidence linking extreme heat to preterm birth, stillbirth, hypertensive disorders, placental complications, fetal growth restriction, and other adverse maternal and neonatal outcomes.

Then they deliver the uncomfortable part: most heat-health action plans still do not name pregnancy as a high-risk condition.

One review found that only 52% of heat-health action plans published between 2004 and 2024 listed pregnant individuals as a key population to protect, and none addressed heat risks for mothers, newborns, and children in any comprehensive way. When researchers ranked which vulnerable groups actually received targeted heat interventions, pregnant women came in last, behind older adults, people with chronic disease, children, and even athletes (9,10,11).

If public health agencies can warn elderly patients and people with chronic disease during heat waves, pregnant women should not remain an afterthought in climate-health planning.

A 5-degree Celsius rise in average temperature during early pregnancy was associated with a nearly seven-fold increase in the risk of preeclampsia in one study. In another, each 1°C increase in daily temperature added almost 4 additional preterm births per 1,000 live births.

These are not projections. These are findings from published epidemiological studies, and they point to a pregnancy risk factor that most clinicians never discuss with patients: heat.

Every summer, millions of pregnant people are exposed to temperatures that research links to serious complications. Yet heat exposure rarely appears on a prenatal checklist. It should.

What Happens to the Pregnant Body in Heat

Pregnancy changes how the body handles heat. Core body temperature drops slightly. The threshold for sweating lowers. Blood volume and skin blood flow increase. These are adaptive changes that help the body dissipate heat more effectively (1,2). The placenta itself generates heat as it transfers thermal energy from the fetus to the mother, increasing the mother’s overall heat load (3).

For healthy pregnant people doing moderate exercise, these adaptations work well. Research shows that pregnant individuals can safely exercise for up to 35 minutes at 80% to 90% of maximum heart rate in conditions of 25°C (77°F) and 45% relative humidity (2). There is no evidence that pregnancy itself increases the risk of heat injury compared to non-pregnant individuals.

But “no increased risk of heat injury” is not the same as “no increased risk from heat.” The real concern is not heatstroke. It is what sustained high temperatures do to the placenta, to blood flow, and to the developing fetus.

The Evidence: Preeclampsia, Preterm Birth, Stillbirth

A time-to-event study of 8,090 births in South Africa examined the relationship between ambient temperature and hypertensive disorders of pregnancy. The findings were striking. Exposure to a mean temperature of 23°C, compared with 18°C, between 2 and 5 weeks of gestation was associated with a significantly increased hazard of preeclampsia (hazard ratio 7.68; 95% CI, 1.72 to 34.28). The absolute numbers tell the story even more clearly: preeclampsia rates were 4.4% among those exposed to 18°C throughout pregnancy, compared to 29.2% among those exposed to 23°C in that critical early window. That translates to approximately 248 additional cases per 1,000 pregnancies (4).

A systematic review and meta-analysis of 47 observational studies, primarily from high-income countries, examined heat and preterm birth. Each 1°C increase in daily temperature was associated with a 1.05-fold increase in the odds of preterm birth (95% CI, 1.03 to 1.07). Against a baseline preterm birth rate of 7.9%, this corresponds to an absolute risk of 8.28%, or 3.8 additional preterm births per 1,000 live births per degree of warming (5).

The same review reported that each 1°C increase in temperature was associated with a 1.05-fold increase in stillbirth risk (95% CI, 1.01 to 1.08) (5). These are small relative increases that, applied across millions of pregnancies, translate to thousands of affected families.

The mechanisms are not fully understood, but the leading hypotheses center on dehydration reducing maternal blood volume, which decreases placental blood flow and raises oxytocin concentrations, potentially triggering preterm contractions (1,3). Heat exposure during pregnancy may also increase systemic inflammation (1).

Why the Same Temperature Is Not the Same Risk

The largest synthesis of this evidence to date reviewed 198 studies across 66 countries (12). It found that each 1°C rise in temperature increased the odds of preterm birth by about 4%, and that during heat waves the odds rose by 26%. The same review found higher odds of stillbirth, of congenital anomalies (48% higher odds), and of gestational diabetes (28% higher odds). These numbers line up with the smaller reviews and strengthen the case that heat is a real, measurable risk in pregnancy.

But the risk is not the same everywhere, and this is the part that often gets lost. The danger from heat depends not only on how hot it gets, but on whether the body is used to that heat. In the United States, a study of extreme heat and hospitalization during pregnancy found that the harm was driven mostly by women in historically cooler counties, not by women in places that are usually hot (13). A separate analysis found a clear link between temperature and both maternal death and stillbirth in the Democratic Republic of the Congo, where temperatures swing widely, but found no such link in Senegal, where heat is high and steady year-round (9,14). The body appears to adapt to heat it knows. A 30°C day in a cool climate may carry more risk than a 35°C day in a place that is hot every day.

For patients, this carries a practical lesson. The first heat wave of the season, and any sudden jump in temperature, deserves more caution than a steady hot spell your body has already adjusted to.

Mental Health and Heat in Pregnancy

A matched analysis from North Carolina covering 2011 to 2019 found that heat wave periods were associated with a higher risk of severe mental illness among pregnant individuals (relative risk 1.13; 95% CI, 1.08 to 1.19). No association was found between heat waves and perinatal mood or anxiety disorders specifically (6). This distinction matters: the risk appears to affect those with pre-existing severe mental illness, a population that already faces barriers to adequate prenatal care.

Early Pregnancy: Neural Tube Defects

Maternal hyperthermia in early pregnancy has long been recognized as a risk factor for congenital anomalies. During the August 2003 Paris heat wave, when mean daily temperatures exceeded 35°C for 14 consecutive days, researchers documented a 13% increase in neural tube defects among births conceived during that period, an estimated 6 additional cases (7). This is why pregnant people are advised against saunas: core body temperature above 39°C (102°F) is associated with higher risk of congenital anomalies.

Who Is Most at Risk

The populations most vulnerable to heat in pregnancy are those with the least ability to avoid it. Many pregnant people work in hot, humid environments performing physically demanding labor: agricultural work, factory work, jobs without adequate cooling. Some continue working in extreme heat late into pregnancy because they cannot afford to lose income. Workers may lack access to water or sanitation facilities, compounding dehydration risk.

People with pre-existing conditions including diabetes, cardiovascular disease, and mental illness face heightened risk. Low-income communities with limited access to air conditioning are disproportionately affected. This is not just a clinical issue. It is a health equity issue.

Pregnancy Keeps Getting Left Off the List

Here is the part that should bother every clinician. The biology is established. The epidemiology is published. And yet the systems built to protect people during heat waves still skip over pregnancy. Only about half of heat-health action plans even mention pregnant women, and none lay out a full plan to protect mothers and newborns from extreme heat (10). When you line up the groups that get targeted heat protection, pregnant women rank below athletes (11). Acknowledging the vulnerability of pregnancy carries its own risks, including more anxiety and, in some settings, fewer job opportunities (9). That concern is real. But silence is not protection. The answer is accurate information and concrete accommodations, not leaving pregnant women to figure it out alone.

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