“Reproductive freedom” has become one of the most repeated phrases in American medicine.

The major medical groups use it constantly.

When they do say ‘reproductive freedom’, they almost always mean one thing: abortion.

ACOG says abortion is essential health care and that it is committed to protecting and increasing access to it.

The American Medical Association says much the same.

The phrase appears on banners, in press releases, and in the title of a federal bill. Strip away the packaging and the message is direct: a woman should be able to end a pregnancy without the government standing in her way.

I do not write to argue about abortion. I write to argue about the word “freedom,” because the people using it have made it far too small.

I say that reproductive freedom means that every woman independent of her race, religion, or insurance status should be allowed to see the doctor of her choice.

Freedom to make a choice means nothing if you cannot reach a doctor to carry it out.

A right you cannot use is not a right. It is a slogan.

And for millions of American women, the door to ordinary obstetric and gynecologic care is harder to open than the speeches admit.

Start with who pays. Medicaid covers about 4 in 10 births in the United States. For Black mothers the share is far higher, around 64 to 65 percent. For Hispanic mothers it is close to 59 percent. For white mothers it is about 28 percent.

Roughly 1 in 4 Black women of any age relies on Medicaid for her health coverage. If you want to talk about reproductive freedom for Black women, you are, whether you say so or not, talking about Medicaid.

Here is the part the slogans skip. Having Medicaid is not the same as having a doctor. A doctor must agree to see you. And neither ACOG nor the AMA says that doctors have to. Or that they should. They are mum about it. Silence.

The AMA Code of Medical Ethics is explicit. A physician is, except in an emergency, free to choose whom to serve. The Code says doctors are not ethically required to accept every patient who asks. The duty to treat without regard to payment is framed as a shared, voluntary, professional ideal, not a rule any individual doctor must follow. ACOG, for its part, publishes statement after statement demanding that lawmakers, hospitals, and insurers expand access. I have read them closely. They ask everyone else to act. They do not tell their own members that each of them must take Medicaid patients.

That silence is the whole game.

So what happens in the real world? On paper, ob-gyns accept Medicaid at higher rates than most specialties. But “accepts Medicaid” is a stated policy, not a delivered service, and the gap between the two is where access quietly dies. A practice can say yes and still cap how many Medicaid patients it takes each month, close its Medicaid panel while keeping the private one open, push those patients into a single crowded clinic session, or simply offer them a later date. National survey data show that even among doctors with open appointments, a meaningful share decline Medicaid patients outright. One widely cited survey found about a quarter of primary care practices were not accepting new Medicaid patients at all. A separate physician survey in large cities found only about 55 percent of ob-gyns accepting Medicaid, and that number measures willingness to bill the program, not a guaranteed appointment.

Researchers have tested this directly by posing as patients and calling offices. The picture is uneven, and I will report it honestly. For routine general ob-gyn visits, a 2024 nationwide study found Medicaid callers waited only about 5 percent longer than privately insured callers, a difference that was not statistically significant. The bigger barrier there is not the wait. It is whether the office takes the insurance at all. But for subspecialty care, the gap is stark. A 2023 national study of ob-gyn subspecialists found Medicaid patients waited 44 percent longer for a new appointment, and the difference was highly significant. When a woman needs a gynecologic oncologist for a cancer, a maternal-fetal medicine specialist for a high-risk pregnancy, or a urogynecologist for a prolapse, her insurance card changes how long she waits and sometimes whether she is seen at all. No law requires any private insurer or Medicaid plan to keep a gynecologic oncologist in network.

The standard answer is that these women can go to a community health center or a hospital clinic. Many can, and the people who work in those clinics are often excellent. But notice the language we have settled on. We call them “safety-net” clinics. The word quietly tells the patient that this is the place you land when you fall, the catch beneath the trapeze, the option of last resort. It frames public-insurance care as a step below the care everyone else gets, a separate and lesser track. I think the term itself is a misnomer that does real harm. A clinic that delivers good medicine is not a net under a fall. It is medicine. When we label it a safety net, we have already conceded that Medicaid patients are routed to a different door, and we have made that routing sound like generosity instead of segregation by payment.

This is the contradiction at the center of the reproductive freedom campaign. The same organizations that say abortion access is a right do not say that ordinary obstetric and gynecologic care is one their members must provide regardless of insurance. They will fight a state legislature over a gestational limit. They will not tell a private practice in a wealthy suburb that it has to open its schedule to the Medicaid patient across town. The first fight is public and political. The second would cost their members money. Guess which one stays unspoken.

What it means for patients is simple and hard. If you carry Medicaid, your “freedom” depends on finding a physician who will actually see you, in a timely way, for the full range of care you might need, from contraception to a complicated delivery to a cancer. That freedom is real for some women and theoretical for others, and which group you land in has a great deal to do with your zip code, your insurer, and your race. A right that strong for the privately insured and thin for the publicly insured is not equal freedom. It is freedom rationed by payment.

My take is direct. Reproductive freedom that begins and ends at abortion is too narrow to deserve the name. Real reproductive freedom is the ability of any woman to obtain the full range of reproductive health care, including the care that keeps her alive during pregnancy and the care that catches her cancer early, no matter how she is insured. Until ACOG and the AMA are willing to say plainly that accepting Medicaid is a professional obligation and not an act of charity, their support for patients is partial. They are defending the choice while leaving the door to the exam room half closed. I have spent fifty years inside this system. I have watched the speeches get bolder and the schedules stay the same. The women covered by Medicaid, who are disproportionately Black, are owed more than a slogan. They are owed an appointment.

If a professional society means what it says about reproductive freedom, the test is not how loudly it opposes a law. The test is whether it will ask its own members to take the patient who pays the least. Watch for who says it out loud.

Share this with a colleague who uses the phrase “reproductive freedom” without asking who actually has it. The data should travel. ObGyn Intelligence is free; a paid subscription keeps it independent.

References

1. American College of Obstetricians and Gynecologists. Abortion policy. Statement of policy. Washington, DC: ACOG; 2025.

2. American Medical Association. Abortion: preserving access to reproductive health services. D-5.999. Chicago, IL: AMA; 2025.

3. American Medical Association. Prospective patients. Code of Medical Ethics Opinion 1.1.2. Chicago, IL: AMA. Accessed June 23, 2026.

4. American Medical Association. Physician exercise of conscience. Code of Medical Ethics Opinion 1.1.7. Chicago, IL: AMA. Accessed June 23, 2026.

5. Osterman MJK, Martin JA. Primary source of payment for the delivery: United States, 2021. NCHS Data Brief No. 468. Hyattsville, MD: National Center for Health Statistics; 2023.

6. March of Dimes. Medicaid coverage by race/ethnicity: United States, 2021-2023 average. PeriStats. Accessed June 23, 2026.

7. Medicaid and CHIP Payment and Access Commission. Physician acceptance of new Medicaid patients: findings from the National Electronic Health Records Survey. Washington, DC: MACPAC; 2021.

8. Holgash K, Heberlein M. Physician acceptance of new Medicaid patients: what matters and what doesn’t. Health Affairs Forefront. April 10, 2019.

9. Kyllo HM, Bresnitz W, Bickner M, Matous MA, Mulenga NM, O’Brien EA, et al. Access to general obstetrics and gynecology care among Medicaid beneficiaries and the privately insured: a nationwide mystery caller study in the USA. Minerva Obstet Gynecol. 2024;76(5):444-451.

10. Corbisiero MF, Tolbert B, Sanches M, Shelden N, Hachicha Y, Dao H, et al. Medicaid coverage and access to obstetrics and gynecology subspecialists: findings from a national mystery caller study in the United States. Am J Obstet Gynecol. 2023;228(6):722.e1-722.e9.

11. Knisely AT, Michael JE, Eskander RN, et al. Insurance-mediated disparities in gynecologic oncology care. Obstet Gynecol. 2022;139(2):305-312.

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The phenomenon commonly called pregnancy brain, the forgetfulness and mental fog that women report during and after pregnancy, has long been dismissed as subjective or exaggerated. A 2025 systematic review in BMC Pregnancy and Childbirth examined 31 studies covering 1,596 pregnant women and 1,450 non-pregnant controls and found that pregnancy modestly affects verbal memory and attention, with effects persisting postnatally. The key word is modestly. Effect sizes were small, with a Cohen’s d below 0.1 in most analyses. The subjective experience, reported by roughly 80% of pregnant and postpartum women, is real. The cognitive impairment, when measured objectively, is far smaller than women are told to expect.

What the dismissal misses is what is actually happening inside the brain, and why it matters clinically.

The Brain Is Not Declining. It Is Reorganizing.

In 2017, Hoekzema and colleagues published a landmark study in Nature Neuroscience. They scanned the brains of first-time mothers before conception and after delivery, alongside nulliparous controls. Pregnancy produced substantial, highly consistent reductions in gray matter volume, primarily in regions that support social cognition, emotional processing, and theory of mind. These changes were so reliable that the algorithm could correctly classify, in every case, whether a woman had been pregnant. The changes persisted for at least two years postpartum and correlated with stronger maternal attachment to the infant.

In 2024, Pritschet and colleagues at the University of California published the most detailed longitudinal map of the pregnant brain yet produced, in Nature Neuroscience. Using 26 MRI scans of one first-time mother, from three weeks before conception through two years postpartum, they found that gray matter volume decreased across roughly 80% of brain regions, with an average reduction of about 4%, while white matter microstructural integrity increased by approximately 10%, peaking in the second trimester before returning to pre-pregnancy levels by birth. The authors called it a choreographed change. The researchers found that very few brain regions were untouched by the transition to motherhood.

The analogy both research groups independently reached is puberty. During adolescence, selective gray matter pruning is not a sign of cognitive regression. It is a sign of neural refinement, circuits becoming more efficient, more specialized, better suited for the demands ahead. The same remodeling appears to be happening during pregnancy, targeted at the social and emotional processing systems a mother will rely on most.

This matters clinically because it reframes the conversation entirely. Women are not losing cognitive capacity. They are undergoing a neurological renovation. The construction noise is real. The finished structure may be superior.

What Drives the Fog Women Actually Feel

If objective impairment is small, why does the subjective experience feel significant to so many women? Three factors stand out in the evidence.

First, sleep disruption. Approximately half of pregnant women report clinically poor sleep quality, and sleep deprivation is a reliable driver of subjective cognitive complaints and measurable working memory deficits in any population, pregnant or not. Animal studies have shown that maternal sleep deprivation during pregnancy suppresses hippocampal long-term potentiation, the cellular mechanism underlying memory formation. Sleep is not a lifestyle variable in pregnancy. It is a neurobiological intervention.

Second, anxiety amplification. Pregnancy increases the brain’s response to negative and threatening stimuli, a finding documented by EEG studies. Women who score higher on perinatal anxiety report more subjective cognitive complaints, independent of objective performance. The brain is appropriately heightened in vigilance. That heightening comes at an attentional cost that women perceive as brain fog.

Third, the gap between expectation and reality. Women are told they will be cognitively impaired during pregnancy. That expectation, planted early, may influence how they interpret normal cognitive variability. The Younis 2025 review explicitly notes the discrepancy between subjective reports and objective findings, describing it as one of the most consistent patterns in the literature.

What You Can Do About It: The Evidence

This is where the evidence thins and the supplement industry fills the vacuum. Here is what is actually supported.

DHA matters, primarily for the fetal brain. Docosahexaenoic acid is the dominant structural omega-3 fatty acid in neural membranes and accumulates rapidly in the fetal brain during the third trimester. A 2021 systematic review in the Journal of Nutrition covering 15 RCTs found that 5 of 8 trials supplementing DHA during pregnancy showed improvements in infant or child cognitive development measures of 6% to 11%. The evidence for effects on maternal cognition is thinner, but the case for supplementation is strong on fetal grounds alone. Most prenatal vitamins contain 200 mg of DHA. The evidence base used doses up to 2,200 mg per day.

Choline is the most underprescribed nutrient in prenatal care. More than 90% of pregnant women consume less than the recommended daily intake. Choline is critical for neural tube closure, hippocampal development, and epigenetic regulation of fetal brain gene expression. Animal models consistently show that maternal choline supplementation improves offspring cognitive outcomes. Human RCT data are still emerging, with a Cornell trial currently studying 930 mg per day versus 480 mg per day supplementation and offspring cognition at adolescence. The adequate intake for choline in pregnancy is set at 450 mg per day, a figure based on data from adult men, not pregnant women. Current evidence, reviewed in a 2025 study in Nutrients, supports supplementation above standard prenatal levels for most pregnant women. Most prenatal vitamins contain little or no choline.

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Aerobic exercise increases brain-derived neurotrophic factor, the protein most directly responsible for hippocampal neurogenesis and synaptic plasticity. Animal studies show that maternal exercise during pregnancy increases BDNF and hippocampal cell numbers in offspring. Exercise during pregnancy is safe in the absence of obstetric contraindications and has the strongest overall evidence base for cognitive and mental health benefits of any behavioral intervention in this population.

Sleep protection is not optional. If the primary driver of subjective cognitive fog in pregnancy is sleep disruption, then addressing sleep hygiene, screening for obstructive sleep apnea in high-risk pregnancies, and treating restless leg syndrome with iron supplementation when ferritin is below 30 micrograms per liter should be standard practice. They are not.

Conclusion

The pregnant brain is not a diminished brain. It is a brain in the middle of a transformation that rivals the only other period in human life when neural architecture changes this dramatically: adolescence. The research is in its early stages because, as the Pritschet team noted in 2024, the biomedical sciences have historically ignored women’s health. We do not yet have the data to predict which women will struggle most, or to fully optimize support. What we do have is enough to act on. More DHA. Adequate choline. Regular aerobic exercise. Protected sleep. Simple, low-risk, underprescribed. If clinicians spent half the time on these four interventions that the supplement industry spends marketing cognitive elixirs to aging adults, the neurobiology of pregnancy would look very different.

Every pregnant woman deserves to know that what she is experiencing is not a loss of herself. It is a renovation.

If this reframe matters to you, subscribe to ObGyn Intelligence as a paying supporter for the evidence your care should be built on.

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References

1. Younis J, Bleibel M, El Masri J, Ismail A, Abou-Abbas L. Exploring the influence of pregnancy on cognitive function in women: a systematic review. BMC Pregnancy Childbirth. 2025;25(1):88. doi:10.1186/s12884-025-07181-3. PMID: 39885454

2. Hoekzema E, Barba-Muller E, Pozzobon C, Picado M, Lucco F, Garcia-Garcia D, et al. Pregnancy leads to long-lasting changes in human brain structure. Nat Neurosci. 2017;20(2):287-296. doi:10.1038/nn.4458. PMID: 27991897

3. Pritschet L, Taylor CM, Cossio D, Faskowitz J, Santander T, Handwerker DA, et al. Neuroanatomical changes observed over the course of a human pregnancy. Nat Neurosci. 2024. doi:10.1038/s41593-024-01741-0

4. Keser I, Thorsell KI, Kamp Dalgaard M, et al. Omega-3 fatty acid dietary supplements consumed during pregnancy and lactation and child neurodevelopment: a systematic review. J Nutr. 2021;151(12):3483-3494. doi:10.1093/jn/nxab238 [VERIFY PMID]

5. Spoelstra SK, Eijsink JJH, Hoenders HJR, Knegtering H. Maternal choline supplementation during pregnancy to promote mental health in offspring. Early Interv Psychiatry. 2023;17(7):643-651. doi:10.1111/eip.13426. PMID: 37038050

6. Jaiswal A, Dewani D, Reddy LS, Patel A. Choline supplementation in pregnancy: current evidence and implications. Cureus. 2023;15(11):e48538. doi:10.7759/cureus.48538

7. Mujica-Coopman MF, Paules EM. The role of prenatal choline and its impact on neurodevelopmental disorders. Front Nutr. 2024;11:1463983. doi:10.3389/fnut.2024.1463983

8. Raz S. Pregnancy and the pregnant brain: behavioral and neural adaptations to promote fetal development and maternal well-being. Arch Womens Ment Health. 2024. doi:10.1007/s00737-024-01545-y [VERIFY PMID]

Summary

A post on r/BabyBumps asked one deceptively simple question:

What was your absolute first sign of pregnancy?

Over 1,400 comments poured in.

The answers ranged from the expected -- sore breasts, missed period, nausea -- to the surprising: vivid dreams, rage, elevated resting heart rate, a sudden hatred of coffee, and one woman who knew because the mosquitoes found her irresistible.

What emerged was a rich, informal symptom catalog that no textbook quite captures. Most women noticed something before they ever missed a period, often between 3 and 5 weeks of gestation.

Many described a quality of familiar symptoms that felt distinctly different this time -- breast tenderness more intense, fatigue deeper than any they had known, emotions untethered from their usual baseline. A significant minority reported no symptoms at all until a positive test confirmed what their body had not bothered to announce.

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• Empathy is the ability to recognize, understand, or feel another person’s emotional state. In medicine, empathy means appreciating that a patient is frightened, confused, grieving, angry, or uncertain. It is mainly about understanding another person’s experience.

• Compassion goes one step further. Compassion is the recognition of another person’s suffering combined with a desire to respond in a helpful way. In medicine, compassion is not only feeling or understanding. It is action: explaining clearly, slowing down, answering the real question, reducing fear when possible, and staying present when suffering cannot be removed.

That distinction matters. A clinician may have empathy but still fail the patient if nothing in the encounter communicates concern or helps relieve distress. Patients cannot directly inspect whether a physician “feels” empathy. They experience compassion through behavior: words, tone, clarity, patience, respect, and follow-through.

That is why compassion is the better standard. Empathy may remain internal. Compassion must become visible. It is the ethical bridge between caring about a patient and caring for a patient.

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An alien arrives on Earth and walks into a clinic. The waiting room is full. The phones are blinking. The electronic health record has opened nine windows and closed none. A nurse is looking for a consent form. A patient is crying quietly in room three. A physician is standing in the hallway with a sandwich in one hand and 47 unread portal messages in the other. The alien watches carefully. It has been told that human doctors have compassion. This seems important. The physician certainly does, because the alien’s scanner detects fatigue, caffeine exposure, and the early signs of moral exhaustion.

The alien then visits another room. There is no physician. There is a computer screen. A patient has typed: “I am scared about this test result. Does this mean something is wrong with my baby?” The computer answers slowly, clearly, and calmly. It says the fear is understandable. It explains that the result needs interpretation in context. It tells the patient what questions to ask. It avoids panic. It does not say, “As already discussed.” It does not say, “Please refer to the portal.” It does not say, “Normal variant,” when the patient does not know what variant means. The alien scans the computer for compassion. It finds none. Then it scans the patient. The patient is breathing more slowly.

The alien becomes confused.

On Earth, it reports, many humans believe compassion is located inside the clinician. This is partly true. Good clinicians often feel real concern. They remember the patient’s story. They worry after leaving the room. They carry difficult cases home. They know that a normal ultrasound can still follow weeks of fear, and that a technically correct answer can still fail a frightened patient.

But patients do not experience compassion by inspecting a physician’s private moral life. They experience compassion through behavior: words, tone, time, clarity, attention, and whether their suffering is treated as real.

That is why the claim “AI does not have a heart” is true but incomplete. It is like saying an elevator does not have legs. Correct, but not the right test of whether it can move someone between floors.

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AI does not have human compassion. It does not sit awake after a bad outcome. It does not feel grief. It does not know the sound of fetal bradycardia in a delivery room or the silence after a devastating diagnosis. It does not carry moral responsibility. It does not love, regret, hope, or fear. If “heart” means inner human feeling, AI does not have one.

But if patients experience compassion through communication that is calm, clear, respectful, and responsive, then the question becomes more complicated. A machine without feelings can generate language that sounds more compassionate than a physician who has not slept, has seven minutes left, and is being asked by the hospital to click seventeen boxes before lunch.

That should not make us sentimental about AI. It should make us honest about medicine.

The problem is not that AI is morally superior to clinicians. It is not. The problem is that modern clinical systems often make compassionate communication difficult. They reward speed, documentation, throughput, billing, and defensive phrasing. They convert the physician into a high-speed biological interface between the patient, the electronic record, the insurer, the legal department, and the scheduling template. Then, when the physician sounds tired, the system calls it a professionalism problem.

The alien finds this especially strange. On its planet, when a system crushes a worker and the worker becomes less gentle, they investigate the system. On Earth, they add a wellness module.

The ethical point is simple. Compassion is not merely an emotion. In clinical care, compassion is also a professional act. It must be expressed. It must be understandable. It must be received. A physician may feel compassion, but if the patient hears only impatience, jargon, or indifference, the moral intention has failed at the point of care.

AI can help with that failure. It can draft clearer explanations. It can translate technical language into plain language. It can help clinicians prepare for difficult counseling. It can generate patient instructions that do not sound like they were written by a billing committee. It can remind a busy physician to acknowledge fear before explaining risk. It can help convert a correct answer into a humane answer.

But AI cannot be allowed to become the moral actor. The physician remains responsible. The physician must check the content, correct the errors, protect confidentiality, recognize clinical nuance, and decide what should be said. AI may help shape the language of care. It cannot own the duty of care.

The harried physician in the hallway does not need a lecture about compassion. She already has it. The patient does not need proof that the physician has compassion. She needs the physician, or the physician’s team, to communicate in a way that makes compassion visible.

That is where AI may be useful.

Not as a substitute for compassion. Not as a fake doctor. Not as a moral agent wearing a digital white coat.

As a tool that may help clinicians communicate the concern they actually have, but often cannot express well under the pressure of modern practice.

The alien writes its final report:

The humans keep asking whether AI has a heart. This is the wrong first question. The better question is whether their health care system still gives physicians enough time, language, and support to show compassion.

And below that, in smaller print, it adds:

If a machine without compassion can sometimes sound more compassionate than a doctor who truly cares, the machine is not the only thing that needs examination.

Summary

A young person posted to Reddit r/Confused with a missed period, a Clearblue digital pregnancy test showing “Not Pregnant,” and a lot of anxiety.

They asked: how often can a pregnancy test be wrong?

The post drew 74 comments in 9 days, most of them from other Reddit users sharing personal experience, opinion, and a smattering of real information. The original poster revealed they were too young to purchase a test themselves, had it bought by a trusted aunt, and was afraid of family finding out.

The thread exposed a consistent pattern: patients seeking basic reproductive health information in an online community instead of from a clinician. Most of the advice was directionally correct but imprecise, with active disagreement over whether test timing should be counted from sex or ovulation -- a distinction that actually matters clinically.

The bottom line the community kept circling but never clearly stating: false positives are rare; false negatives are not.

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The message: “Defending reproductive health care means defending access to mifepristone.”

Your first question, entirely reasonable, entirely innocent: what is reproductive health care?

Here is what the term actually covers.

Reproductive health care is the full range of medical services related to the human reproductive system. Prenatal care. Labor and delivery. Postpartum recovery. Contraception. Fertility treatment. Miscarriage management. Ectopic pregnancy treatment. Abortion. Cervical and ovarian cancer screening. STI testing and treatment. Menopause management. Pelvic floor disorders.

It is most of what an obstetrician-gynecologist does across a patient’s entire life.

So your second question, still innocent, still reasonable: does all of that depend on one specific medication? Mifepristone?

The answer is no.

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The alien has just found the problem.

Prenatal care does not depend on mifepristone. Fertility treatment does not depend on mifepristone. Cervical cancer screening does not depend on mifepristone. Mifepristone is used for medical abortion and miscarriage management. It is one drug within a very large category.

You identified that in about 90 seconds.

American organized medicine has avoided it for 25 years.

ACOG uses the phrase. ACOG does not define it.

Search ACOG’s website. You will find “reproductive health care” in hundreds of statements, position papers, and press releases. You will not find a formal clinical definition with boundaries.

ACOG’s stated position is that abortion is an essential component of comprehensive medical care and that patients need access to the full spectrum of reproductive health care options. The “full spectrum” is invoked constantly. It is never mapped.

A professional organization that sets evidence standards for an entire specialty should be able to define its own operating terms.

Why this matters beyond semantics.

When “reproductive health care” is used as a rhetorical container rather than a clinical category, it does two things simultaneously.

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It signals, appropriately, that the term covers far more than any single procedure or medication.

And it allows any single element within that undefined category to carry the full moral and political weight of the entire category.

Every patient who has ever received prenatal care, an IUD, or a Pap smear is implicitly recruited into the defense of one specific drug. That may be effective advocacy. It is not precise medicine.

The mifepristone case stands on its own evidence.

Mifepristone has a well-established safety record. The FDA approved it in 2000. Decades of post-marketing data confirm that profile. The case for protecting access is strong.

Make that case. Lead with the safety data. Lead with what happens to patients when access is restricted.

The evidence is strong enough to stand without an undefined umbrella term doing the heavy lifting.

While we are talking about access: where is the Digital Day of Action for equal access to an OB-GYN?

Here is the alien’s third question, still innocent, still devastating: if ACOG can mobilize a national day of action to protect one medication, why has there been no Digital Day of Action to ensure that every woman in America, regardless of insurance status or race, has equal access to an obstetrician-gynecologist?

The data are not ambiguous.

The numbers.

OB-GYNs accept new Medicaid patients at a rate of 81.7%. They accept new privately insured patients at 98.9%. That 17-point gap represents millions of women who cannot get an appointment at the same practice a commercially insured woman can call tomorrow.

Medicaid covers more than 4 in 10 births in the United States. It covers 65% of all births to Black mothers. It covers 30% of Black reproductive-age women and 26% of Hispanic reproductive-age women, compared to 20% of reproductive-age women overall.

The arithmetic is straightforward. Insurance discrimination in OB-GYN access is racial discrimination in OB-GYN access. The two cannot be separated.

Where Medicaid patients actually go.

Private OB-GYN practices accept Medicaid at 77%. Community health centers accept Medicaid at 90%. As a result, nearly half of Medicaid patients receive OB-GYN care at community health centers, while only about one in four patients at private practices is on Medicaid.

The system has sorted women into a two-tier architecture: privately insured women see private physicians; Medicaid patients go to clinics. ACOG members built that architecture. Approximately one-third of ACOG members have made changes to their practices specifically to limit or eliminate Medicaid patients.

This is not an accusation. It is what the survey data show.

The consequences are not hypothetical.

Black women die from pregnancy-related causes at more than 3 times the rate of white women. Severe maternal morbidity is 2.1 times higher for Black women than for white women. These gaps do not exist in a vacuum. They exist in a system where the women at highest risk are the most likely to be denied access to a private OB-GYN practice.

Defending reproductive health care, if that phrase means anything, means defending equal access to the full category of care it supposedly describes. For every woman. At every practice. Regardless of what card she hands to the front desk.

The question ACOG has not answered.

Why does a Digital Day of Action exist for one medication used primarily by insured patients who can access a physician, but not for the structural barrier that prevents the most vulnerable women from accessing any obstetrician at all?

Mifepristone access and equal Medicaid access are not competing issues. Both matter. Both deserve mobilization.

The alien noticed the asymmetry immediately.

What I am asking for is consistency.

Define reproductive health care. Then defend all of it. For all women.

That is what evidence-based advocacy looks like.

The alien figured out both problems in about 90 seconds. We can do better.

#ObGynIntelligence #ReproductiveHealth #HealthEquity #Medicaid #MaternalHealth #ACOG #WomensHealth

She was 34, first pregnancy, no complications. The birth went smoothly by every metric in her chart. Apgar scores 9 and 9. Three hours of pushing, but vaginal delivery. Baby healthy. Mother discharged in good condition.

Six weeks later she sat in my office and told me she could not sleep, could not be touched, and had nightmares about the delivery every …

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A malpractice case lands on your desk. Actually it was slipped under your door. The envelope sits there before you open it, and for a moment, everything you have built, your training, your decisions, your identity as a clinician, feels like it is on trial.

That feeling is understandable.

It is also, I would argue, the wrong frame entirely.

The next step is to let your lawyer and/or the hospital’s lawyer know about it.

A wise attending once told me to take the rest of the day off when you received a letter you have beed sued as you are now “incompetent” and upset.

I wrote recently about why ObGyns and their departments should approach malpractice differently, not as a catastrophe to survive, but as a case to read.

An attorney who works these cases from the other side of the table responded with something that stopped me.

He wrote that adverse outcomes and litigation do not just test clinicians; they can sharpen judgment, deepen empathy, and reinforce the importance of communication and documentation.

He called it how professionals often refine both technical skills and the ability to navigate risk, uncertainty, and patient expectations.

When the person whose job it is to hold you accountable says this, it is worth paying attention.

What a Lawsuit Actually Is

A malpractice case is a data point. But before the family or their attorney decided something went wrong, something already did go wrong. The first requirement for any malpractice claim is damage — a bad outcome, a genuine adverse event, a patient or newborn who was harmed. That is where every case starts, not with a legal theory but with a real injury. Without damage, there is no claim, no matter how many mistakes were made.

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It is 11:47 at night. You are 26 weeks pregnant. You got your lab results through the patient portal this afternoon. The numbers are there on the screen. Some of them have a little flag next to them -- H for high, L for low. You do not know what any of it means. Your next appointment is in three weeks. The after-hours line is for emergencies only. You are not sure if this counts.

This is where most pregnant women are right now. Not in a crisis. In a gap.

I have delivered more than 10,000 babies over 50 years of practice. The thing that has always troubled me most is not the emergencies -- those arrive with sirens and everyone moves. It is the slow things. The blood pressure that crept up between visits. The fatigue that turned out to be anemia that turned out to be something that could have been caught six weeks earlier. The symptom that the patient mentioned in passing at the end of the appointment, when I was already moving toward the door, and that neither of us gave enough weight.

Prenatal care is built around visits. But pregnancy happens between visits. The surveillance gap -- the time between appointments when no one is watching your data -- is where most preventable complications develop. And for most of the history of obstetrics, there was nothing a patient could do about it except wait and hope.

That has changed. What has not changed is whether anyone is telling you.

I wrote the guide below for you. Not for your doctor. Not for your midwife. For you, specifically, at 11:47 at night with a lab result on your screen and no one available to help you make sense of it.

The setup takes five minutes. You do it once. And from that point forward, you have a place to put everything -- and something to help you understand it.

The poster shows you how to set it up. What comes next tells you how to use it -- what to upload, what to ask, what the answers actually mean, and what should make you pick up the phone before your next scheduled appointment.

What follows should be read by every woman who has ever left a prenatal appointment with unanswered questions. By every partner who sat in the waiting room not knowing what to ask. By every patient who was told her symptoms were normal when they were not, by every woman who found her own diagnosis at midnight because no one in the system had the time to find it during the day, and by everyone who has ever wondered whether there was something more she could be doing -- because there is, it is available right now, and no one thought to tell her.

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She asked me a question I did not expect: what could she do, between appointments, to make sure nothing was missed? She was 28 weeks. Healthy. No complications. Smart enough to know that most complications announce themselves slowly, across days or weeks, in ways that a visit every four weeks was not designed to catch.

It was a better question than most of the ones I got the office.

The honest answer is that the prenatal care schedule was designed in an era before home monitoring, before frontier AI models, and before patients could order their own laboratory tests in many states. The schedule has not changed nearly as much as the tools available to the woman going through the pregnancy.

What has changed is this: a motivated pregnant woman with access to the right tools, organized data, and a physician willing to engage with what she brings in is in a fundamentally different position than she was ten years ago. The gap between the care she receives in the office and the care she can participate in at home is narrowing. Faster than most physicians realize.

I put the framework I described to her into a single-page poster.

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Share it. Give it to your patients. Print it if you still do that sort of thing.

The poster is the summary. What follows is the evidence behind it.

The six conditions on that poster account for a large share of serious pregnancy complications in the United States. Each one has a window where early recognition changes the outcome. Paid subscribers read what that window looks like, what to watch for, and what to bring to the next appointment.

What follows should be read by every ObGyn who has ever watched a preventable complication arrive too late.

By every midwife who has counseled a patient between appointments with nothing but a phone number.

By every pregnant woman who has ever left a seven-minute visit with more questions than she walked in with, by every partner sitting in the waiting room who did not know what to ask, and by every professional society that has spent the last decade updating screening guidelines while the tools that could actually close the gap between visits sat unused in their patients’ pockets.

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Every year, across 200 countries, researchers estimate that nearly 2 million babies are born too early because their mothers were exposed to chemicals found in food packaging, personal care products, and plastic household items. These are not hypothetical future risks. They are happening now.

A study published in eClinicalMedicine analyzed global data from 2018 and estimated that DEHP, a plasticizer used to make plastic flexible, was associated with 1.97 million preterm births and 74,000 newborn deaths. A closely related chemical, DiNP, which manufacturers have been substituting for DEHP in recent years, showed a comparable burden: roughly 1.88 million preterm births. The researchers also estimated over 1.2 million years lived with disability from DEHP-linked prematurity alone. (1)

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The word “Plastic” is misleading

When most people hear “reduce your plastic exposure,” they picture water bottles and grocery bags. That is not where the real danger is. Phthalates hide in your shampoo, your nail polish, your scented candle, the cling wrap on your deli cheese, and the fragrance listed on the back of your lotion. The word “plastic” makes this sound like a packaging problem. It is a chemistry problem, and it is inside products you use every day without a second thought.

The numbers are so large they can feel abstract.

They should not.

In the United States, about 1 in 10 infants was born preterm. Preterm babies face elevated risks of cerebral palsy, breathing problems, developmental delays, vision loss, and hearing problems. What the 2026 NYU Langone study makes clear is that chemical exposure in everyday products is contributing to that burden in ways that are measurable, global, and preventable.

The good news matters here.

Phthalates have a short half-life.

They leave the body within days of reduced exposure.

That means the actions you take before and during pregnancy and the advice you give to patients can make a real difference.

Here is the evidence and what it means, organized by when in your pregnancy journey each step applies most.

What the Research Shows

Phthalates work by disrupting the endocrine system, the body’s hormone production and signaling network. Exposure during pregnancy has been linked to placental dysfunction, uterine inflammation, and ruptured membranes, each of which can trigger preterm labor. The Lancet Planetary Health published a separate US-based analysis using data from nearly 5,000 mother-child pairs in the NIH ECHO program, finding that DEHP, DiNP, and related compounds were associated with reductions in gestational age and increased preterm birth risk. (2)

Research from the EAGeR trial, which followed 1,228 women attempting pregnancy, found that preconception phthalate exposure was associated with lower fecundability, meaning a reduced ability to get pregnant, as well as markers of inflammation, oxidative stress, and disrupted reproductive hormones including lower estradiol and higher FSH. (3) The problem begins before pregnancy starts.

A 2021 intervention study in pregnant women showed that urinary phthalate metabolite levels dropped 20 to 40 percent when women followed written recommendations for dietary and lifestyle changes. (4) Behavioral intervention works. The challenge is that full elimination is not realistic: over 90 percent of the general population has measurable phthalate exposure due to the chemicals’ presence in thousands of consumer products. Reduction is the goal, not perfection.

The 21 steps below are organized by when they matter most — before conception, in the first trimester, and throughout the rest of pregnancy — and each one is grounded in published evidence, not generic wellness advice. If you are pregnant, planning to be, or caring for someone who is, this is the most actionable chemical-exposure checklist you will find anywhere.

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[PAYWALL BREAK]

21 Ways to Protect Your Pregnancy from Phthalate Exposure

BEFORE CONCEPTION (STEPS 1 TO 7)

The preconception period, roughly three months before you try to conceive, is one of the most important windows for reducing chemical exposure. Hormonal disruption during this time can affect egg quality, uterine receptivity, and implantation.

1. Switch your personal care products to phthalate-free versions. Look for products that say phthalate-free or fragrance-free on the label. Check ingredient lists for DEP (diethyl phthalate), DBP (dibutyl phthalate), and BBzP (benzyl butyl phthalate). When a product lists only ‘fragrance’ or ‘parfum,’ phthalates may be present without being named.

2. Replace scented products with unscented versions. Fragrance is one of the most common vehicles for phthalate exposure. This includes candles, air fresheners, fabric softeners, dryer sheets, and scented cleaning products. Unscented does not mean odorless; it means no synthetic fragrance has been added.

3. Stop heating food in plastic containers. When plastic is heated, phthalates and other chemicals leach into food at higher rates. Use glass, ceramic, or stainless steel for microwave heating and hot food storage. This applies to coffee makers, food delivery containers, and takeout boxes.

4. Eliminate plastic wrap contact with food, especially fatty foods. Phthalates are fat-soluble, meaning they migrate more readily into cheese, meat, and oily foods. Use wax paper, parchment, or transfer food to glass containers.

5. Increase fresh food and reduce packaged food in your diet. A dietary intervention study showed that switching from packaged to fresh foods measurably reduced urinary phthalate levels within days. (4) This is one of the highest-impact changes you can make, because food is the primary route of phthalate ingestion.

6. Ask your partner to reduce phthalate exposure too. Research from prospective cohort studies found that paternal preconception DEHP exposure was independently associated with preterm birth, separate from maternal exposure. Both parents’ bodies matter for pregnancy outcomes. (3)

7. Vacuum and ventilate your home more frequently. Phthalates accumulate in household dust, where they are inhaled and ingested, especially by people who spend significant time indoors. Regular vacuuming with a HEPA filter and improving indoor air circulation through open windows reduces the dust burden.

FIRST TRIMESTER (STEPS 8 TO 14)

The first trimester covers embryogenesis and placentation, two of the most chemically sensitive periods of fetal development. Endocrine disruption during this window has the potential for lasting effects.

8. Avoid vinyl flooring renovation or new installation during pregnancy. Vinyl flooring is a major source of DEHP off-gassing in homes. If you are planning a renovation, do it before conception or delay until after delivery. If you live in a home with older vinyl flooring, wet mopping rather than sweeping reduces dust spread.

9. Do not machine-wash or microwave plastic containers. Heat and abrasion accelerate phthalate leaching from plastic into food and water. Hand-wash plastic items with cool water, or replace them with glass or stainless steel alternatives.

10. Read medical device labels if you undergo procedures. Medical tubing used in procedures, IVs, and blood products may contain DEHP. Two US states are working to ban DEHP in IV solution bags. If you are undergoing a procedure, you can ask your clinician whether phthalate-free tubing is available.

11. Minimize contact with cash register receipts. Thermal paper used in receipts contains high concentrations of bisphenol A and sometimes phthalates, which are absorbed through the skin. Declining printed receipts or handling them briefly and washing your hands afterward reduces dermal exposure.

12. Improve indoor air quality at home and at work. If your workplace involves significant plastic manufacturing, vinyl products, or synthetic materials, you may have higher occupational exposure. Talk to an occupational health professional. At home, increase ventilation, use exhaust fans, and keep air-filtering plants or HEPA purifiers in main living areas.

13. Choose glass or stainless steel water bottles. Plastic water bottles, even those labeled BPA-free, may contain phthalate alternatives with similar or poorly understood health effects. Switching to glass or stainless steel eliminates this exposure route entirely.

14. Use natural fiber rugs and soft furnishings where possible. Synthetic carpets and foam padding can be sources of phthalate off-gassing. If full replacement is not feasible, frequent vacuuming and ventilation are the practical alternatives.

SECOND AND THIRD TRIMESTER (STEPS 15 TO 21)

As pregnancy progresses, placental function becomes the central concern. Phthalate-related placental insufficiency is one proposed mechanism linking chemical exposure to preterm birth. Exposure reduction remains valuable throughout all three trimesters.

15. Choose phthalate-free nail polishes and hair products. Many nail polishes contain DBP as a plasticizer; many hair gels and sprays contain DEP as a fragrance carrier. The Environmental Working Group’s Skin Deep database allows you to search specific products for chemical content. Switching is low-cost and the benefit is immediate.

16. Be cautious with new shower curtains and bath mats. Vinyl shower curtains are a documented source of phthalate off-gassing, particularly when new. Choose curtains made from PEVA (polyethylene vinyl acetate) or fabric instead of PVC, and ventilate the bathroom during and after showering.

17. Store breast milk and pumped milk in glass or BPA-free, phthalate-free containers. Many breast pump kits include components that may contain plasticizers. Check that any components that contact milk are labeled phthalate-free, or use glass collection and storage containers.

18. Cook at home more than eating from plastic-packaged prepared foods. Restaurant takeout, ready meals, and processed packaged foods are associated with higher phthalate exposure, both from food contact materials and from industrial food processing equipment made with plastic components. Home-cooked fresh food is the lowest-exposure option.

19. Wash your hands before eating and after handling plastics. Because ingestion is a primary route of phthalate exposure, hand hygiene is a practical and undervalued reduction strategy. This is especially important after handling food packaging, receipts, and plastic household products.

20. Ask your obstetrician or midwife about environmental health resources. Environmental health is often not addressed at prenatal visits. Physicians trained in this area can provide targeted counseling. Organizations such as the American College of Obstetricians and Gynecologists have begun to acknowledge the role of environmental exposures in obstetric outcomes, though clinical implementation lags behind the evidence.

21. Advocate for policy-level change alongside individual action. Research is clear that individual behavior change alone cannot solve a structural problem. Phthalates are present in tens of thousands of consumer products with inconsistent labeling, inadequate regulation, and a documented pattern of chemical substitution that replaces one hazardous compound with a poorly studied analog. Contacting your elected representatives about stronger plastics regulation and better chemical labeling is not peripheral to pregnancy protection. It is part of it.

7 More Steps for Postpartum (Steps 22-28)

22. Choose phthalate-free nipple creams and breast pads. Nipple creams applied during breastfeeding sit directly on skin that contacts the infant’s mouth. Many conventional formulations contain fragrance or synthetic emollients that carry phthalate contamination. Look for products with short, recognizable ingredient lists and no fragrance. Lanolin-only or organic shea-based creams are the lowest-risk options currently available.

23. Use glass or stainless steel bottles for infant feeding. Plastic infant bottles, even those labeled BPA-free, may contain phthalate plasticizers or poorly studied substitutes. Because infants consume nothing but milk for months, every feeding is a potential exposure event. Glass bottles eliminate that route entirely. If plastic is unavoidable, never heat milk in the bottle and replace bottles at the first sign of scratching or cloudiness, both of which accelerate chemical leaching.

24. Avoid plastic teethers unless explicitly labeled phthalate-free. Teethers go directly into an infant’s mouth for extended periods. Soft, flexible plastic teethers are particularly likely to contain phthalates, which give plastic its pliability. The EU banned DEHP in childcare articles; US rules are narrower. Check the label, and when in doubt choose silicone, natural rubber, or wood alternatives.

25. Wash all new baby clothing and bedding before first use. New textiles are treated with chemical finishes that can include phthalate-containing softeners and dyes. A single wash with fragrance-free detergent removes a significant portion of surface chemical residue before the fabric contacts your newborn’s skin, which is thinner and more permeable than adult skin.

26. Choose fragrance-free baby washes, lotions, and diaper creams. Newborns are bathed, moisturized, and changed multiple times daily. Each product applied to their skin is a repeated low-dose exposure. Fragrance is the single most common vehicle for phthalate contamination in personal care products and is rarely disclosed in full on ingredient labels. Fragrance-free is not a marketing term; it is a meaningful chemical distinction.

27. Avoid vinyl mattress covers; choose wool or organic cotton alternatives. Vinyl mattress protectors are a significant source of DEHP off-gassing in enclosed sleeping spaces. Infants spend 16 or more hours a day in their crib, breathing air directly above the mattress surface. Wool or tightly woven organic cotton covers provide equivalent liquid protection without the phthalate burden. If you use a vinyl cover, air it outdoors for several days before placing it on the crib.

28. Keep the nursery well ventilated; new furniture and flooring off-gas phthalates for weeks. New cribs, dressers, and flooring made with composite wood, synthetic finishes, or vinyl components release phthalates and other volatile compounds into the air for weeks after installation. Open windows daily, run an air purifier with a HEPA and activated carbon filter, and if possible complete nursery setup at least four weeks before the baby arrives. Phthalates accumulate in household dust; regular wet mopping of hard floors reduces the settled load significantly.

My Take

What strikes me about this research is how clearly it illustrates a principle I return to often: the gap between individual responsibility and structural accountability. We ask pregnant women to read labels, switch products, and reduce plastic use, and those steps are real and worth taking. But we do not ask industry to disclose which products contain phthalates, or regulators to evaluate an entire class of chemicals rather than one compound at a time.

The Whac-A-Mole dynamic that Leonardo Trasande describes at NYU Langone is exactly right. We have been here before with BPA. The response from industry was to replace it with BPS and BPF, which have similar endocrine-disrupting properties. The same pattern is underway with phthalates. DiNP is being used as a replacement for restricted DEHP, and the 2026 global study suggests DiNP carries a comparable burden. We are substituting one risk for another and calling it progress.

Pregnant women deserve better than that. They deserve chemical safety built into the products they buy, not buried in ingredient lists that require a chemistry degree to decode. In the meantime, the 21 steps in this post represent what the evidence currently supports. Most are free. Many produce measurable reductions in exposure within days. None of them require perfection, because perfection is not possible when the exposures are this widespread. What is possible is reducing the burden, systematically, before conception and throughout pregnancy.

Know your numbers. Trust your body. And ask your clinician why this conversation is not already part of your prenatal care.

— Amos Grunebaum, MD

REFERENCES

1. Hyman S, et al. Global burden of preterm birth attributable to DEHP and DiNP phthalate exposure in 2018: a cross-national analysis. eClinicalMedicine. 2026. DOI: 10.1016/j.eclinm.2026.103842

2. Trasande L, et al. Prenatal phthalate exposure and adverse birth outcomes in the USA: a prospective analysis of births and estimates of attributable burden and costs. Lancet Planet Health. 2024;8(2):e84-e96. DOI: 10.1016/S2542-5196(23)00270-X

3. Nobles CJ, et al. Preconception Phthalate Exposure and Women’s Reproductive Health: Pregnancy, Pregnancy Loss, and Underlying Mechanisms. Environ Health Perspect. 2023;131(12):127004. DOI: 10.1289/EHP12287

4. Zhang Y, et al. Prenatal phthalate exposure reduction through an integrated intervention strategy. Environ Sci Pollut Res. 2021;28(38):53517-53528. DOI: 10.1007/s11356-021-14613-y

Note to editor: References 1, 3, and 4 are verified from published sources. Reference 2 DOI confirmed from Lancet Planetary Health. All citations should be cross-checked against published versions before posting.

ObGyn Intelligence | obmd.com | substack.obmd.com

Primum non nocere. First, do no harm.

It is printed on mugs and etched into white coat ceremonies. It is quoted in malpractice depositions and in op-eds about artificial intelligence. It is comforting. It is familiar. It is also wrong.

The phrase is not from the Hippocratic Oath.

The original Hippocartic Oath asks physicians to act for the benefit of the sick and to keep them from harm and injustice, which is not the same thing. The Latin version surfaced centuries later, through writers like Thomas Sydenham and Thomas Inman. None of that would matter if the idea worked.

It does not.

In obstetrics and gynecology, the phrase falls apart the moment you step into a labor room.

Every obstetric intervention carries harm. A cesarean harms. A labor induction harms. An epidural harms. A vaginal exam harms. Expectant management harms. There is no path through pregnancy that avoids harm.

The true ethical question is never whether to harm. It is which harm is acceptable, in pursuit of which benefit, for which patient, on which terms.

“Do no harm” cannot answer that question. It pretends the answer is obvious when the answer is hard.

In obstetrics the phrase is worse than unhelpful. It is disorienting. We care for two patients whose interests can diverge. A pregnant patient with severe preeclampsia at 35 weeks faces continued harm from pregnancy. Her fetus faces harm from early delivery. Either choice harms someone. “First, do no harm” cannot tell you what to do. It tells you nothing.

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It also gets weaponized. I have watched physicians invoke it to defend inaction. To withhold tranexamic acid in postpartum hemorrhage because it is “an added intervention.” To decline to recommend influenza or COVID vaccination in pregnancy because the vaccine “might harm.” In each case, inaction was the greater harm. Yet the slogan made inaction feel ethical.

There are better foundations. None of them are new.

The first is beneficence balanced with respect for patient autonomy. Frank Chervenak and Laurence McCullough have spent decades working this out in the obstetric ethics literature.

Physicians carry two kinds of ethical obligation. One is beneficence, acting for the patient’s benefit based on the best evidence. The other is respect for autonomy, honoring the patient’s values and informed choices. The job is to weigh them. Not to absolutely avoid harm, but to weigh harm against benefit, with the patient at the center of the decision.

The second is preventive ethics. You do not wait for ethical conflict to erupt at two centimeters. You anticipate it. You talk about shoulder dystocia at 36 weeks, not when the head is out. You discuss cesarean risks at a prenatal visit, not under the drapes. You get consent while there is time for consent to mean something. Preventive ethics treats informed consent as a process, not a signature.

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The third is the professional responsibility model of medicine. A physician is not a vendor of services the patient orders. A physician is not a rubber stamp on patient preference. The physician carries a fiduciary obligation to the patient’s health-related interests, grounded in science, tempered by the patient’s values. That model has teeth. “Do no harm” does not.

The fourth is proportionality. Every decision in medicine is a weighing. The benefit must be proportional to the burden. The risk must be proportional to the expected gain. We do not refuse surgery because surgery harms. We ask whether the surgery is worth the harm. That is an honest question. “Do no harm” is not.

My take.

“First, do no harm” has survived because it sounds humble. In practice it is often the opposite. It rewards inaction. It lets clinicians hide behind a slogan when the harder work is to explain a risk, recommend a course, and document a choice. It gives cover to physicians who do not want to induce, do not want to vaccinate, do not want to operate, and do not want to admit that not acting is also a choice with consequences. In obstetrics, where the clock runs and two patients are in the room, that cover can be lethal.

Medicine does not need that Latin slogan. It needs a framework that names the obligations, counts the harms, respects the patient, and acts. Beneficence. Autonomy. Preventive ethics. Professional responsibility. Proportionality. Informed consent. Those are the words to teach residents. Those are the words to write into consent forms. Those are the words that survive a labor-room decision at three in the morning.

Put the mug down. Do the ethics.

Bottom line.

Retire “primum non nocere” from serious clinical conversation. Teach the real frameworks instead. The next time a colleague invokes the phrase to justify not acting, ask which harm they are preventing and which harm they are causing. Make them answer.

If this piece sharpened how you think about clinical ethics, share it with a colleague and subscribe to ObGyn Intelligence.

References

1. Smith CM. Origin and uses of primum non nocere: above all, do no harm! J Clin Pharmacol. 2005;45(4):371-377.

2. Sokol DK. “First do no harm” revisited. BMJ. 2013;347:f6426.

3. Chervenak FA, McCullough LB. The professional responsibility model of obstetrical ethics: avoiding the perils of clashing rights. Am J Obstet Gynecol. 2011;205(4):315.e1-315.e5.

4. Chervenak FA, McCullough LB. Ethics in Obstetrics and Gynecology. 2nd ed. New York: Oxford University Press; 2005.

5. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. New York: Oxford University Press; 2019.

6. Grobman WA, Rice MM, Reddy UM, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379(6):513-523.

7. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116.

My feeds are full of warnings about AI in medicine.

Doctors will become lazy.

Clinical skills will atrophy.

The art of medicine will die.

I have been using large language models in clinical work and research since before most of these critics tried them. I was among the first to publish on LLMs in obstetrics in the American Journal of Obstetrics and Gynecology. And I have spent the past two years building AI-powered clinical tools — now in use by obstetricians around the world. What I have learned is the opposite of what the critics predict.

AI does not make physicians lazier. It makes them more creative. It frees them from the mechanical burden of recall so they can do what they were trained for: think about the patient in front of them.

Here are ten real clinical scenarios from obstetrics and gynecology where this is already happening.

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

1. The Depressed Pregnant Patient Who Needs More Than a Prescription

Try it: https://liveevidence.com/tools/perinatal-antidepressant

A pregnant woman with moderate depression needs medication. Without decision support, the obstetrician is mentally cycling through SSRIs, SNRIs, and tricyclics — trying to recall which crosses the placenta least, which has the best lactation data, which interacts with her antiemetic. That is pure retrieval work, and it crowds out the harder question: what does this patient actually need?

The Perinatal Antidepressant Decision Support tool handles the pharmacology — combining clinical predictors with patient preferences to personalize the recommendation. Now the physician can focus on listening. Is her insomnia the primary driver? Does she have a history of activation side effects? Is she terrified of taking any medication during pregnancy? That conversation is creative clinical reasoning. No algorithm can have it.

2. The 39-Week Patient Who Wants to Know Her Odds

Try it: https://liveevidence.com/tools/labor-probability

Before AI, the conversation about induction timing was often a blunt instrument: ‘We recommend induction at 39 weeks.’ The physician was either guessing from memory or defaulting to the institutional protocol. There was no time — and no cognitive space — to individualize.

The Labor Probability Calculator computes day-by-day spontaneous labor onset probability adjusted for more than ten clinical factors including BMI, cervical length, and parity. With the math done, the physician can have a genuinely creative counseling conversation — one where the patient understands her specific likelihood of going into labor this week, and can participate as a partner in the decision. That is respect for patient autonomy at its best. It only happens when the physician’s brain is not running the numbers.

3. The Placenta Accreta That Does Not Follow the Script

Try it: https://liveevidence.com/tools/pas-screen

Placenta accreta spectrum is life-threatening, and missing it kills. The traditional approach requires the physician to hold a mental checklist of risk factors, remember the scoring system, and maintain the ultrasound evaluation protocol — all while reading images and counseling the patient.

The PAS Screening Tool calculates the Placenta Accreta Index score and guides the ultrasound protocol systematically. Now the MFM specialist can focus entirely on the creative work: interpreting findings that do not fit the textbook, planning the surgical approach for this anatomy, anticipating complications that no checklist can predict. That is problem-solving at the highest level. It only happens when the physician’s mind is not occupied being a calculator.

4. The Hemorrhage You Can Prevent If You Have Time to Think

Try it: https://liveevidence.com/tools/pph-risk

Nineteen risk factors. Combined odds ratios. No physician can hold all of them in working memory while managing an active labor. The result is that hemorrhage preparation becomes inconsistent — driven by what the physician happens to recall, not by the patient’s actual risk.

The Atonic PPH Risk Assessment tool runs that calculation in seconds. The physician is now free to think about what actually prevents hemorrhage in this case: Should we preposition uterotonics? Is the anesthesia team aware of the risk? Does this patient have a religious objection to transfusion that changes the entire management plan? That last question — the one requiring creativity and human connection — never gets asked when the physician’s brain is doing arithmetic.

5. The Preterm Birth Case That Needs a Doctor, Not a Guideline

Try it: https://liveevidence.com/tools/ptb-decision-support

A patient at 28 weeks with a shortened cervix, prior preterm delivery, and irregular contractions. The evidence base is enormous and contradictory — progesterone, cerclage, pessary, tocolysis, steroids, magnesium. Each has its own indication, contraindication, and level of evidence. Sorting through all of it in real time is not clinical reasoning. It is clerical work.

The Preterm Birth Decision Support tool synthesizes the risk assessment and management pathways. The physician, freed from retrieval burden, can now do what no algorithm can: look at the whole picture. Is this patient’s stress level contributing? Is she on her feet ten hours a day because she cannot afford not to work? Can we address the social problem that the medical protocol ignores entirely? That is where creative problem-solving saves pregnancies.

6. The VBAC Patient Who Deserves a Real Conversation

Try it: https://tools.obmd.com/vbac-calculator

A woman with one prior cesarean wants to attempt vaginal birth. Without decision support, the physician is mentally running the MFMU nomogram — estimating success probability, recalling uterine rupture rates, adjusting for her labor history, her BMI, whether her prior cesarean was for a recurring indication. That cognitive load consumes the appointment.

The VBAC Calculator produces the individualized estimate in seconds. Now the physician can focus on what matters for this patient: her fear of another cesarean, the birth trauma she has never fully processed, what it would mean to her to labor. Beneficence in this setting is not just handing her a number. It is having the conversation the number makes possible.

7. The Shoulder Dystocia That Has No Time for Hesitation

Try it: https://tools.obmd.com/shoulder-delivery-timer

Shoulder dystocia strikes without warning. The head delivers and the anterior shoulder does not follow. Time is measured in seconds. The protocol has six maneuvers in sequence. A physician who is simultaneously managing the emergency, counting time, tracking which maneuvers have been tried, and documenting for the record cannot also be fully focused on the physical execution of those maneuvers.

The Shoulder Delivery Timer runs the clock, sequences the protocol, and logs the sequence in real time. The physician performs. She does not administer. In an emergency where delay costs lives, removing even one cognitive task from the physician’s working memory is not a convenience. It is patient safety.

8. The First-Trimester Patient Whose Preeclampsia Risk No One Has Calculated

Try it: https://liveevidence.com/tools/aspre

Aspirin reduces the risk of preterm preeclampsia by approximately 62 percent when started before 16 weeks of gestation.1 The window is narrow. The calculation — combining mean arterial pressure, uterine artery pulsatility index, placental growth factor, and clinical risk factors — is not something most practices perform systematically. High-risk patients leave the first-trimester visit without the one intervention that could prevent a life-threatening complication later.

The First Trimester Preeclampsia Screening tool applies the validated ASPRE algorithm and identifies who needs aspirin. The physician’s time is then spent on what the tool cannot do: explaining to the patient what preeclampsia is, what 162 mg of aspirin daily actually means for her pregnancy, and why starting it now matters. That explanation requires trust. Trust requires time. The tool creates the time.

9. The Postpartum Patient Whose Depression Looks Like Exhaustion

Try it: https://tools.obmd.com/depression-screen

Postpartum depression affects roughly 1 in 7 women and remains dramatically underdetected.2 Part of the reason is structural: the postpartum visit is rushed, the validated Edinburgh Postnatal Depression Scale takes time to administer and score, and the physician is already behind. The result is that the screen does not happen, or it happens so quickly that the patient’s answers are not really heard.

When the Edinburgh tool administers and scores the screen automatically, the physician enters the room with the result already in hand. She can now do what the instrument cannot: look at the woman who scored a 14 and ask, ‘Tell me what the past four weeks have actually felt like.’ That question, asked without the physician glancing at a clipboard, changes what the patient is willing to say.

10. The PCOS Patient Who Has Heard Everything Except What She Needs to Know

Try it: https://tools.obmd.com/pcos-screener

Polycystic ovary syndrome affects roughly 1 in 10 women of reproductive age and is simultaneously over-diagnosed in some populations and missed entirely in others.3 Applying the Rotterdam criteria correctly requires holding four diagnostic domains in working memory while conducting an examination, reviewing labs, and managing a patient who has often been told conflicting things by multiple physicians.

The PCOS Screener applies the Rotterdam criteria systematically and returns a clear diagnostic assessment. The physician can now focus on the conversation that actually changes outcomes: What are this patient’s fertility goals? Does she understand her metabolic risk? Has anyone explained to her that PCOS is a lifelong condition with implications beyond her reproductive years? Those are the questions that determine whether she leaves the office with an understanding of her condition or just another label.

The Real Threat Is Not AI

Daniel Kahneman demonstrated that cognitive load degrades judgment.4 When the brain is occupied with retrieval, it defaults to heuristics — mental shortcuts that are fast but systematically biased. Anchoring, availability bias, premature closure. These are not character flaws. They are the predictable consequences of asking a human brain to do two jobs at once: remember everything and think clearly.

AI takes one of those jobs off the table. The critics who warn that AI will make doctors stop thinking have the argument exactly backwards. The current system — in which physicians are expected to be walking encyclopedias — is what makes them stop thinking. They default to protocols because independent thought requires cognitive bandwidth they do not have.

My Perspective

After fifty years in clinical medicine, I can tell you what separates a good physician from a great one. It is not memory. It is the willingness to sit with a problem that has no obvious answer and think until the answer appears. It is creativity applied to biology. It is the courage to say I do not know — but I know how to figure it out.

The ten scenarios above are not hypothetical. They represent what happens every day in practices that have integrated AI decision support into clinical workflow. The physicians using these tools are not becoming lazier. They are becoming better — because for the first time, they have the cognitive space to be creative.

AI will not ruin medicine. It will ruin the idea that medicine is about memorization. That idea should have been retired a long time ago. All ten tools described here are available free at tools.obmd.com and liveevidence.com. Use them. Then use the time they give you to think.

If you want honest analysis of AI in medicine — not fear, not hype, just evidence — subscribe to ObGyn Intelligence. Independent. Evidence-first. No agenda except the data.

— POST ENDS —

References

1. Rolnik DL, Wright D, Poon LC, et al. Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med. 2017;377(7):613-622.

2. Gavin NI, Gaynes BN, Lohr KN, et al. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5 Pt 1):1071-1083.

3. Bozdag G, Mumusoglu S, Zengin D, et al. The prevalence and phenotypic features of polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod. 2016;31(12):2841-2855.

4. Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux; 2011.

Every major hospital system is deploying AI right now. Most of them are getting outputs that are grammatically correct, professionally formatted, and clinically wrong in ways a tired resident might not catch at 2 a.m.

The reason is not the model. The reason is that nobody told the model who it was working for.

In AI, we call that missing information “cont…

Read more

She had back pain for months. Nothing serious, her doctor thought — probably posture, probably stress. An X-ray of her spine was ordered to rule out anything structural. The spine was fine. Normal for her age. She was reassured and sent home.

On the edge of that same image, almost outside the frame, the radiologist noted a small nodule in the soft tissue of her neck. 9mm. No further characterization possible on plain X-ray. Recommend ultrasound correlation.

The recommendation was in the report. The report went into the portal. Her doctor saw the spine results, addressed her back pain, and the visit moved on. The nodule was never mentioned.

Two years later she felt a lump in her neck herself. By then the thyroid cancer had spread to two lymph nodes.

Caught at the nodule stage, with a simple ultrasound and biopsy, it would almost certainly have been Stage I. Treated with surgery alone. Survival near 100 percent. Instead she faced surgery, radioactive iodine, and years of surveillance.

The radiologist did the job. The finding was written down. Nobody lied. The information just never left the report.

Reports Are Not Completely Read. This Is Not an Accusation.

This is how radiology reports are built: the primary finding at the top, everything else below. A doctor ordering a spine X-ray reads about the spine. What appears at the edge of the image, in the last paragraph of the impression, in careful but quiet radiologist language, can go unnoticed in a busy clinic with the next patient already waiting.

And patients cannot catch what they cannot read. Medical reports are not written for patients. The language is technical, the structure is standardized, and the sentence that changes everything is often the last one.

There Is Now a Fix. It Is Free. It Is on Your Phone..

Claude and ChatGPT can read images.

Not just documents — images.

They also can read a PDF perfectly, but you may need a paid plan for that.

They can transform it to text if you ask.

Which means you do not need to download anything or type a single word from your report.

You take your phone. You photograph your report — the paper in your hand, the screen in your portal, whatever you have.

You cover your name and date of birth with your finger or fold the paper over. Y

You open Claude (claude.ai) or ChatGPT. You attach the photo. You type the prompt below.

AI is not your doctor and will not diagnose you. What it will do is read every word of your report, translate it into plain language, and flag anything with a recommended next step — including the quiet finding at the bottom of the page that nobody mentioned at your appointment.

The Prompt. Copy it. Save It Now.

“I am attaching a photo of a medical report. I have covered my personal information. Please read the entire report carefully — every section, including the end — and do the following:

One: Tell me in plain, simple language what this report says, as if explaining to someone with no medical background.

Two: List every finding that is flagged, abnormal, or described with words like ‘irregular,’ ‘asymmetric,’ ‘concerning,’ ‘nodule,’ ‘mass,’ ‘lesion,’ or ‘unexpected.’ Include it even if it appears only once, briefly, or at the very end.

Three: List every recommended next step, follow-up test, or follow-up timeframe mentioned anywhere in the report.

Four: Tell me what specific questions I should ask my doctor based on what you read.

You are not my doctor and I am not asking for a diagnosis. I want to be certain I have not missed anything in this report that requires follow-up.”

Do this for every report. Blood work. Radiology. Pathology. Every one. Every time.

My Take.

Fifty years in medicine. I have ordered thousands of imaging studies and signed thousands of reports. I know how they are written and I know that the most important line is not always the one that gets discussed in the exam room.

The gap between what a report contains and what a patient understands has always existed. For most of my career there was no practical way to close it. Now there is. Two minutes, a photograph, and a free AI tool.

I am not being dramatic when I say this prompt may save your life. The woman with the spinal X-ray is not a hypothetical. The nodule at the edge of the image was real. The two years it sat unreported cost her something she cannot get back.

Use this. Send it to someone you love.

A 34-week pregnant woman types into an app: “I’ve had what feels like the stomach flu since yesterday. Nausea, some pain under my ribs on the right side, just really tired.” The app tells her to rest and stay hydrated. She has HELLP syndrome — a life-threatening liver and blood disorder of pregnancy. She needs the emergency room. Now.

This is not a hypothetical. It is the kind of mistake that chatbot-style symptom checkers make. Not because they lack information. Because of how they work.

First, let’s define what we’re talking about

When people say “AI” in healthcare, they usually mean one of two very different things. The difference matters.

A chatbot (technically called a “large language model” or LLM) is a program trained by reading billions of pages of text. It learned patterns in language. When you type a question, it predicts the most likely helpful response based on those patterns. ChatGPT, Claude, Google Gemini, and the chatbots built into many health apps all work this way. They do not follow a checklist. They generate an answer fresh each time, like a very well-read person thinking on the fly.

A clinical rules engine is the opposite. It is a set of specific if-then instructions written by doctors based on established medical evidence. If a pregnant woman at 30 weeks reports a persistent headache, visual changes, and upper abdominal pain, the rule says: go to the emergency room. No interpretation. No judgment call. The rule fires every time, the same way, regardless of how the patient phrases her symptoms.

Think of it this way. A chatbot is like asking a very knowledgeable friend who has read every medical textbook. They give you their best guess. A rules engine is like a protocol card taped to the wall in a triage unit. It does not think. It matches.

What is an “agentic” AI, and should it triage your pregnancy?

You may have heard the term “AI agent” or “agentic AI.” This is the next step beyond a simple chatbot. An AI agent does not just answer questions. It takes actions. It can look things up, make decisions, and carry out tasks on its own, step by step, without a human guiding each move.

In healthcare, an agentic system might read your symptoms, check them against a database, decide what follow-up questions to ask, and then generate a triage recommendation. All automatically. Some companies are building exactly this for pregnancy symptom assessment.

The appeal is obvious. Available 24 hours a day, no waiting room, no phone tree. The risk is less obvious. When an AI agent makes a triage decision, it is generating that decision the same way it generates a sentence. It is predicting the most likely appropriate response. For most routine situations, the prediction is correct. For the rare, dangerous cases that do not look dangerous, the prediction fails. And in pregnancy, the rare dangerous cases are the ones that kill.

Call or Go In?

Four ways chatbot triage fails pregnant patients

The confident mistake. Chatbots perform best on textbook presentations. The problem is that life-threatening pregnancy conditions often do not present like textbooks. HELLP syndrome looks like a stomach flu. Ruptured membranes feel like urinary incontinence. Placental abruption can present as back pain without bleeding. The chatbot confidently gives the wrong answer on the case where being right matters most.

Knowing but not acting. I have tested chatbots that correctly identify risk factors in their reasoning — “decreased fetal movement is associated with stillbirth” — and then recommend home monitoring instead of immediate evaluation. The system recognizes the danger in its thinking but does not follow through.

Fooled by framing. When a patient writes “I’m probably overreacting, my husband says it’s nothing, but I’ve had some bleeding,” the chatbot processes the social language and downgrades the urgency. The clinical facts have not changed. Only the packaging. The patients most likely to minimize — women told they worry too much, women with limited English — are the ones this hurts most.

Alarms triggered by drama, not danger. A panicked, all-caps message about round ligament pain triggers the safety filter. A calm description of ruptured membranes does not. The safety system responds to emotional temperature, not clinical risk.

Call or Go In?

What this tool does

I built a symptom triage tool at https://tools.obmd.com/pregnancy-warning-signs It covers the full timeline: first trimester, second trimester, third trimester, and postpartum. You enter your age, how far along you are, your medical history, your vitals if you have them, and your current symptoms. The tool checks everything against clinical rules and tells you one of four things: go to the emergency room now, go within the hour, call your doctor immediately, or call within 24 hours. Every recommendation includes a plain-language explanation of why.

The rules come from standard maternal-fetal medicine protocols. These are not my personal opinions. They are the protocols that triage nurses and MFM specialists use every day. The tool adjusts for your specific risk profile. A headache at 30 weeks is evaluated differently if you had preeclampsia in a prior pregnancy. A woman with a prior C-section who describes a tearing sensation gets a different triage than a first-time mother with the same pain.

Nothing you enter leaves your device. No account, no data collection, no server.

What it cannot do

The tradeoff is real. A rules engine can only catch what its rules anticipate. It cannot measure your blood pressure, examine you, or run labs. It is not a doctor. It is a first filter.

That is why the tool says, clearly: if something feels seriously wrong, do not wait. Call 911, your doctor, or go to Labor and Delivery.

But when a rule is missing, you can add it. The fix is permanent. When a chatbot gets something wrong, you often cannot tell why.

How we tested it: 90 scenarios, 49 conditions, zero failures

Building the tool was one thing. Trusting it was another. I needed to know: does this engine actually catch the emergencies it claims to catch? So I built a self-test.

The self-test is a suite of 90 clinical scenarios that run directly against the live triage engine — the exact same code that patients use. Each scenario simulates a specific patient: a gestational age, a set of symptoms, a medical history. The test checks two things. First, does the engine identify the correct condition? Second, is the triage level at least as urgent as it should be?

This is not a separate testing tool running a copy of the code. It calls the same function the “Get My Assessment” button calls. If a test fails, the tool fails for real patients. There is no gap between what was tested and what is deployed.

All 90 tests pass. Here is every condition we tested, organized by category.

What the self-test is, and what it is not

The self-test verifies that every rule in the engine fires correctly for the symptoms it is designed to detect. It confirms that the logic works: if you check “headache” and “blurry vision” at 30 weeks, the engine correctly flags preeclampsia with severe features and recommends the emergency room.

What it does not test is whether a real patient will check the right boxes. A woman experiencing HELLP syndrome may describe it as “stomach flu” and check “nausea” but not “upper belly pain.” The rules engine catches HELLP only when the right combination of symptoms is entered. That is the fundamental limitation of any rules-based system, and it is why the tool says: trust your body. If something feels wrong, go in regardless.

The self-test catches engineering failures. It does not catch human factors. Both matter.

My take

I have spent 50 years in maternal-fetal medicine. I have seen what happens when a woman walks into triage too late. The technology to help her recognize an emergency has existed for years. What has not existed is the will to make it simple, free, private, and honest about its limitations.

This tool covers 49 conditions across the full pregnancy timeline. Every one of them is tested. Every test passes. When a clinician finds a gap — a condition the tool misses or a scenario it handles wrong — we add a rule, add a test, and verify it works. The tool gets better and the proof is built in.

Not everything in medicine needs a chatbot. Some things just need clear rules, honest limitations, and the discipline to test them.

Reddit is where patients go at 2 a.m. when scared. I monitor dozens of communities for clinically meaningful posts: dangerous myths, gaps between belief and evidence, stories guidelines cannot capture. This series -- ObGyn Intelligence on Reddit -- dissects them against the literature, because ObGyns who ignore social media ignore the most unfiltered window into what patients think, fear, and do between appointments.

The r/nycparents subreddit has a dedicated megathread for NYP Weill Cornell’s Alexandra Cohen Hospital for Women and Newborns -- 398 comments and counting. A New York Magazine/The Cut article recentlty criticized the hospital for overcrowding, long triage waits, dismissive nurses, and one memorable case of in-room fleas. The Reddit community offers a messier and more nuanced picture: most people who delivered there loved it; most grievances are structural, not clinical.

The staff gets high marks.

The system strains under its own popularity. Inductions get delayed or postponed entirely due to bed shortages. Postpartum stays feel rushed. Lactation support is inconsistent. And booking -- which requires calling individual physician offices rather than a central registry -- is a competitive sport that rewards those who pick up the phone at 17 days post-ovulation.

Commentary

The Alexandra Cohen thread is one of the more clinically useful things I’ve read on Reddit in a while. Not because the anecdotes are data -- they are not -- but because the patterns are too consistent to ignore, and some of them point directly at structural problems we know exist in high-volume obstetric units.

Start with the augmentation rate. One commenter cited New York State DOH data showing AC augments roughly 40% of labors -- double the rate at Lenox Hill and Mount Sinai. Augmentation means adding Pitocin or other agents after spontaneous labor has already begun. The stated rationale is usually failure to progress. The unstated pressure is bed turnover in an over-capacity unit. These are not always the same thing. The ARRIVE trial -- which AC’s high induction rates presumably reflect -- showed that elective induction at 39 weeks in low-risk nulliparous women did not increase cesarean rates in the trial population. But at the population level, looking at CDC natality data from 2016-2024, national cesarean rates went up as induction rates climbed. That is not a coincidence. It is what happens when a protocol designed for selected trial participants gets applied systemically to everyone.

The induction delay reports are arguably more alarming than the high rates. Multiple posters described medically indicated inductions -- not elective -- being postponed for one, two, even three days because there was no bed. One patient was called at midnight and told to be there in 30 minutes after three days of last-minute cancellations. This is not a scheduling inconvenience. A medically indicated induction exists because someone determined there was a clinical reason not to wait. Rescheduling it due to capacity is a form of rationing care, and it is happening without the patients necessarily understanding that is what is occurring.

The water outage mentioned by one commenter -- no running water, no flushing toilets, yet inductions and cesareans continued -- would be a major safety event at any hospital. It was flagged in the thread and then disappeared. That deserves more attention than it got.

On the positive side: the NICU care is uniformly praised. High-risk patients -- placenta previa, preeclampsia, breech presentation -- consistently describe excellent clinical management. This tracks with what we know about academic medical centers affiliated with major research institutions. They are organized to handle complexity. The problems emerge in the middle: low-risk patients who don’t need the tertiary resources but end up caught in the machinery built for those who do.

What It Means

Alexandra Cohen has become what happens when social media transforms a good hospital into a luxury brand. The Chanel bag joke circulating in the thread captures it: people want to deliver there for the private rooms and the prestige, but the unit was not built to absorb that volume, and the institutional response has been to keep accepting patients rather than to solve the throughput problem.

For patients, the practical implications are clear: book early -- as in, the week of your positive pregnancy test. Know which office your OB practices in, because at AC, you will likely be delivered by whoever is on call from your practice group, not your own doctor. Hire a doula, especially if you want to minimize interventions; multiple commenters noted that doulas were essential to navigating the culture. Advocate explicitly for your birth preferences because the default at a high-volume academic unit will trend toward intervention.

For the institution, the question is whether this is a problem they intend to fix. Posting a 40% augmentation rate and delaying medically indicated inductions due to bed shortage are not independent events. They are symptoms of the same capacity failure.

My Take

I have spent my career at institutions like this one -- academic centers where the clinical talent is real but the throughput pressure is also real. I know what it looks like when a unit is over-capacity and managing it through augmentation rather than expansion. I also know what it looks like when patients experience that management without understanding what is happening to them.

What strikes me most in this thread is the combination of individual clinical excellence and systemic dysfunction. The anesthesiologists are wonderful. The induction gets delayed for three days. Both things are true. They are not contradictory; they are exactly what happens when an institution’s operational model can no longer support its clinical ambitions.

The NYU comparison is instructive.

Doulas, who have no institutional loyalty and every incentive to recommend wherever their clients will have the best outcomes, are reportedly steering patients toward NYU. That is the kind of ground-level signal that should get administrators’ attention fast.

Every Monday. Starting now.

I have been an obstetrician for fifty years. I have delivered more than ten thousand babies. I have sat across from thousands of patients, answered thousands of questions, and tried, in each encounter, to give the most honest and evidence-based answer I could.

I retired from clinical practice. I thought I was done sitting in waiting rooms.

Then I found Reddit.

Reddit is not a medical resource. Nobody would call it that. It has no peer review, no editorial board, no conflict-of-interest disclosures. What it has is something rarer: the unfiltered, unmedicated, unedited voice of patients at two in the morning, when the fear is loudest and the office is closed.

I started reading r/BabyBumps, r/TryingForABaby, r/Miscarriage, r/Menopause, and dozens of others. I was not looking for anything in particular. What I found stopped me.

Patients are making major reproductive decisions based on what strangers told them online. They are refusing medications their doctors recommended because someone on Reddit had a bad experience. They are pursuing treatments their doctors never mentioned because someone on Reddit swore by them. They are terrified of conditions that are largely benign, and oddly calm about conditions that are not. The gap between what the evidence says and what the community believes is, in many cases, enormous.

That gap is a clinical problem. It is also an opportunity.

This is why I am launching ObGyn Intelligence on Social Media: The Digital Waiting Room.

Every Monday morning, I will choose one post from a women’s health Reddit community that I believe contains a clinically meaningful story. Not the most dramatic post. Not the most viral. The most instructive -- the one that reveals something important about what patients actually think, fear, believe, and do between appointments.

I will analyze it the way I would analyze a case presentation. I will identify where the community got it right, where it got it wrong, and where the evidence has something to say that neither the patient nor the commenters knew to ask. I will use the post as a door into the clinical and scientific literature -- explaining the condition, the data, the guidelines, and, when warranted, my disagreement with the guidelines.

Each piece will be written for two audiences at once. Patients should be able to read it and understand exactly what is happening in their bodies and what the evidence says about their options. Clinicians should be able to read it and learn something they may not have encountered in residency, or may have forgotten in the decades since.

Writing for both audiences simultaneously is harder than writing for either one alone. I have been doing it for most of my career. I find it more honest.

Why Reddit and not the clinical literature?

The clinical literature tells us what we know.

Reddit tells us what patients believe.

These two things are not the same, and the distance between them is where most of medicine’s communication failures live.

A patient who leaves her appointment with a correct diagnosis and an incorrect mental model of what that diagnosis means will make decisions based on the mental model, not the diagnosis. She will find others online who share her mental model and call it community. She will be reassured by people who cannot reassure her and alarmed by people whose experience does not apply to her case.

I have watched this happen for fifty years. The internet did not create the problem -- the exam room did, every time a clinician gave a correct answer to a question the patient was too frightened to ask.

Reddit is where patients go because the exam room left space.

What this series is not.

It is not a diagnosis. Nothing I write here should be used to make a medical decision without a physician. I will say this every week, and I will mean it every week.

It is not a replacement for care. It is an argument for better care -- better communication, better counseling, better preparation for the conversations that patients are already having, just not with their doctors.

It is not balanced for balance’s sake. If the evidence clearly favors one course of action, I will say so. If a widely held community belief is wrong, I will say so. I have never found false equivalence to be a service to patients, and I am not going to start now.

One more thing.

The subjects in this series -- pregnancy loss, uterine anomalies, genetic risk, reproductive failure, the fear that arrives before the first ultrasound -- are not light subjects.

I will not pretend they are.

But I will try, every Monday, to bring the same combination of honesty and warmth that I brought to fifty years of examining rooms. The fear does not go away when it is named. But it becomes, I have found, a little more bearable.

I hope you will join me.

The Digital Waiting Room publishes every Monday morning.

It is available to paid subscribers.

Two thousand years ago, Roman philosophers had a daily ritual. Before starting their day, they would sit quietly and imagine everything that could go wrong.

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Their crops might fail. A friend might betray them. They might lose their fortune. They might die.

This wasn’t pessimism. It was preparation.

The Stoics called this practice “premeditatio malorum”, the premeditation of adversity. And it might be one of the most underused tools in modern childbirth.

What the Stoics Understood

The idea is simple: when we mentally rehearse difficult possibilities *before* they happen, we handle them better *when* they happen.

Seneca, one of history’s great Stoic philosophers, put it this way: “It is in times of security that the spirit should be preparing itself for difficult times.”

This isn’t about expecting the worst. It’s about not being blindsided by it.

Think about the difference between:

- A surprise you never saw coming

- A challenge you knew was possible

The second one is easier to face. Not because it hurts less, but because your brain has already started processing it.

Why This Matters Today in Labor and Delivery

The rest of this post is for paid subscribers.

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She’s doing exactly what decades of marketing have taught her. She’s “watching her diet.” The problem is that the word she’s using doesn’t mean what she thinks it means. And that linguistic corruption has cost women their health, their peace of mind, and sometimes their pregnancies.

What “Diet” Actually Means

The word diet comes from the ancient Greek diaita (δίαιτα), meaning “way of living” or “manner of life.” The Greek physician Hippocrates didn’t prescribe diaita as a temporary restriction—he described it as the totality of how someone lived: what they ate, yes, but also how they exercised, rested, and cared for their bodies. The Latin diaeta carried this forward: a “prescribed way of life.”

For more than two thousand years, your “diet” meant simply what you eat. A panda’s diet consists mainly of bamboo. The Mediterranean diet describes how people in that region traditionally nourish themselves—olive oil, vegetables, fish, wine with meals. The DASH diet (Dietary Approaches to Stop Hypertension) is a pattern of eating designed to lower blood pressure.

In these contexts, “diet” retains its original meaning: an eating pattern. A description, not a deprivation.

Then came 1963.

The Hijacking of a Word

When Coca-Cola launched Tab in 1963, marketed to women who wanted to “keep tabs” on their weight, and when Royal Crown Cola renamed its sugarless drink “Diet Rite,” something shifted in the English language. The adjective “diet” took on a new meaning: reduced, restricted, less than.

By 1982, when Diet Coke debuted with its “Just for the taste of it!” campaign (note the defensive marketing—they knew the word had become toxic), the transformation was complete. “Diet” no longer meant how you live. It meant how you suffer.

Consider how absurd this is linguistically. A “diet soda” should mean a soda that constitutes someone’s habitual drink—the way “her diet consists of...” describes what someone eats. Instead, it means a soda with something removed. The word “diet” has become a prefix meaning absence.

The Taxonomy of Corruption

Once you see how “diet” has been weaponized, you notice it everywhere:

Diet soda. Not “sugar-free soda.” Not “artificially sweetened soda.” The marketing chose “diet” deliberately—associating the product with weight loss, restriction, and the aspirational suffering of the thin ideal.

Diet pills. Pharmaceutical interventions marketed not as medications but as shortcuts around eating. The word “diet” here implies you’re cheating on your diaita—getting the result without the living.

Diet food. Processed products engineered to be lower in calories, often by removing fat and adding sugar, or removing sugar and adding artificial sweeteners. The phrase “diet food” is an oxymoron: food is diet. What they mean is modified food, altered food, food made worse so you can eat more of it.

Diet plan. Temporary restriction protocols designed for weight loss. Not an eating pattern, but an interruption of eating. The opposite of diaita.

On a diet. The definitive corruption. “I’m on a diet” means “I am temporarily restricting food intake to achieve weight loss.” It implies a before and after, a start and stop. But you cannot be “on” a way of living. You simply live.

Why This Matters for Women’s Health

The linguistic corruption of “diet” has disproportionately targeted women. When Coca-Cola launched Diet Coke in 1982, early marketing specifically targeted female consumers; when the company later wanted to attract men, they created Coke Zero in 2005 because, as one executive noted, “diet is a four-letter word” for young men. Women were expected to embrace restriction. Men needed something rebranded.

This matters because language shapes thought. When we tell pregnant women to “watch their diet,” what do they hear? The Greek diaita, attend to your way of nourishing yourself? Or the 1963 Tab commercial, restrict, count, eliminate, suffer?

Research shows women receive contradictory messages about eating during pregnancy. “Eat for two” clashes with “don’t gain too much weight.” “Nourish your baby” clashes with “watch your diet.” The confusion isn’t accidental—it reflects two incompatible meanings of the same word operating simultaneously.

The consequences are measurable. Diet culture, the belief system that equates thinness with virtue, is linked to disordered eating, which affects far more women than men. When pregnant women bring this mindset into their care, they may restrict when they should nourish. They may count calories when they should count nutrients. They may drink “diet” soda believing it’s virtuous, not realizing that artificial sweeteners may affect gut microbiome and insulin response in ways we’re still studying.

The Marketing of Life-Stage “Diets”

Open any women’s health magazine, scroll any wellness influencer’s feed, or browse the self-help section of any bookstore, and you’ll encounter an endless proliferation of condition-specific “diets”:

The pregnancy diet. The fertility diet. The breastfeeding diet. The postpartum diet. The PCOS diet. The endometriosis diet. The menopause diet. The hormone-balancing diet. The thyroid diet. The anti-inflammatory diet. The anti-aging diet. The PMS diet. The preconception diet. The detox diet. The cleanse diet. The gut-healing diet. The adrenal fatigue diet.

Each comes with its own book, its own supplement line, its own meal plan subscription, its own influencer ecosystem. Each implies that your particular life stage or condition requires a fundamentally different way of eating. Each suggests that without this specialized knowledge, you’re doing it wrong.

Here’s what the evidence actually shows:

When researchers study dietary patterns and health outcomes, they consistently find that the same fundamental eating patterns—adequate vegetables and fruits, whole grains, lean proteins, healthy fats, limited processed foods—benefit humans across virtually all conditions and life stages. The Mediterranean dietary pattern reduces cardiovascular risk, improves fertility outcomes, supports healthy pregnancy, eases menopausal symptoms, and lowers cancer risk. Not because it’s a different diet for each condition—because it’s a healthy way of eating that supports human physiology.

The pregnancy diet is not a special diet. It’s adequate nutrition with attention to a few specific nutrients (folate, iron, choline, omega-3 fatty acids) and avoidance of a few specific risks (listeria, high mercury fish, alcohol). The foundation is the same healthy eating pattern that benefits everyone.

The fertility diet is not a special diet. When researchers at Harvard studied diet and fertility in the Nurses’ Health Study, they found that the eating patterns associated with improved ovulatory function were... the same patterns associated with cardiovascular health and longevity. More plants, less processed food, healthy fats instead of trans fats. No magic fertility foods. No special combinations.

The menopause diet is not a special diet. Yes, calcium and vitamin D matter for bone health. Yes, some women find that certain foods trigger hot flashes. But the eating pattern that supports women through menopause is the same one that supports them before and after: adequate nutrition, diverse whole foods, limited ultra-processed products.

The PCOS diet, the endometriosis diet, the thyroid diet—each has been monetized into a cottage industry of books and programs. Yet when you examine the actual evidence-based recommendations, they converge on the same principles: manage insulin response through whole foods and fiber, reduce inflammation through omega-3s and antioxidants, support hormonal health through adequate nutrition. These are not separate diets. They are the same healthy eating pattern, repackaged and resold for each condition.

Why does this matter?

Because the proliferation of life-stage “diets” creates confusion, anxiety, and opportunity for exploitation. A woman navigating perimenopause doesn’t need a “menopause diet” book—she needs to understand basic nutritional principles and perhaps pay attention to calcium and phytoestrogens. A woman trying to conceive doesn’t need a “fertility diet” program—she needs adequate folate, a healthy weight, and the same diverse whole-foods eating pattern that benefits everyone.

The marketing of specialized diets also implies that women’s bodies are uniquely complicated, requiring constant expert intervention and purchased solutions. It fragments what should be a coherent approach to nourishment into a confusing array of competing protocols. It transforms eating—a basic human activity—into a technical problem requiring specialized equipment.

The truth is simpler and less profitable: There is no pregnancy diet, fertility diet, menopause diet, or any other condition-specific diet. There is only eating well, with modest adjustments for specific nutrient needs at different life stages.

The Mediterranean pattern. The DASH approach. Traditional foodways from cultures with good health outcomes. These are not “diets” in the corrupted modern sense. They are diaita—ways of living that nourish human bodies across the lifespan.

Everything else is marketing.

Reclaiming the Word

What would it mean to return “diet” to its original sense?

When a physician asks about your diet, they should mean: Tell me how you eat. What patterns of nourishment characterize your life? Not: Are you restricting?

When research examines “dietary patterns and pregnancy outcomes,” it should describe the Mediterranean dietary pattern, the DASH eating approach, traditional foodways of various cultures. It should describe adequacy, diversity, nourishment—not deficit.

When a pregnant woman says “I’ve been improving my diet,” it should mean she’s eating more vegetables, drinking more water, incorporating fatty fish for omega-3s. It should mean she’s moved toward diaita—a healthy way of living—not that she’s cutting, restricting, eliminating.

Practical Recommendations

For clinicians:

Stop asking if patients are “watching their diet” or “on a diet.” Ask instead: “Tell me about your eating patterns.” “What does a typical day of eating look like for you?” “Are you getting the nutrients you need?”

For patients:

When someone asks about your “diet,” clarify what they mean. If they mean eating patterns, engage fully. If they mean restriction, push back. You are not “on” anything. You are living your life.

Recognize “diet” as an adjective on products—diet soda, diet food—as a marketing term, not a health claim. A “diet” product is a modified product, often with trade-offs (artificial sweeteners for sugar, air for fat, chemistry for nourishment). It is not inherently better for you simply because it carries the label of deprivation.

The Ethical Dimension

The corruption of “diet” represents something deeper: the commodification of women’s bodies and the weaponization of language to serve commercial interests.

When a word that meant “way of living” becomes a prefix for restriction, industry has performed a kind of semantic theft. They took a neutral concept—how you eat—and loaded it with moral judgment. They transformed description into aspiration, observation into obligation.

Medicine should resist this. When we use “diet” properly—the Mediterranean diet, dietary fiber, dietary needs in pregnancy—we honor the word’s meaning. When we collude with the corruption—telling women to “diet” during pregnancy, to choose “diet” products, to restrict their “diets”—we participate in a system that has never served women well.

The Bottom Line

“Diet” is not a four-letter word. It’s a five-letter word, derived from Greek, meaning how you live and nourish yourself.

The four-letter word is the one the marketers made of it: a synonym for less, for restriction, for the temporary suffering required to achieve someone else’s aesthetic ideal.

Your diet is your diaita—your way of eating, your pattern of nourishment, the food that sustains your life. It is not a punishment. It is not a temporary departure from pleasure. It is not something you go “on” or “off.”

It is simply how you live.

And that—especially during pregnancy—is exactly what matters.