Medicine has a communication problem.

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

The problem is not intelligence.

It is how the human brain works.

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

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

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

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

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

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

This is not about making medicine simplistic.

It is about making complex information understandable.

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

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

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

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

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

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

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

Because education is not measured by what we publish.

It is measured by what clinicians remember at the bedside.

If you want people to understand, write.

If you want them to remember, show.

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

What follows is not a courtroom thriller.

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

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

What the NTSB Is, and Why It Works

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

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

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

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

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What ObGyn Adverse Outcome Review Looks Like in the United States

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

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

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

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

The British Model — and Its Limitations

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

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

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

What We Should Do

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

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

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

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

What We Can Do Right Now

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

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

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

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

My Take

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

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

We can do better.

The NTSB shows us exactly how.

⬇ Try the EXPERIMENTAL tool

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

He was competent, thorough, and honest.

We had reviewed the case together in detail.

The clinical picture was clear.

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

We both understood what it was.

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

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

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

He was correct on every count.

It was not his responsibility.

He was not a doctor.

It was not his place.

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

Prevention is in nobody’s lane.

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

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

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

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

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

The Lawyer’s Constraint Is a System Design

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

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

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

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

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

Who Should Have That Job

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

That body does not currently exist in American obstetrics.

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

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

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

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

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

What Needs to Change at the System Level

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

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

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

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

Conclusion

I do not blame that lawyer.

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

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

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

The clinicians involved in most adverse outcomes are competent.

The lawyers are competent.

The risk managers are competent.

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

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

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

The investigation tool

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

Understanding the Issue

Claudia Goldin, born in 1946, is an American economic historian at Harvard University whose work reshaped our understanding of gender inequality. In 2023, she became the first woman to win the Nobel Prize in Economics on her own. Her research explores how women’s lives change across generations, how fertility decisions shape careers, and how caregiving responsibilities influence earnings and opportunity. Goldin revealed what many women already knew intuitively. Choice is shaped by structure. Ambition is shaped by constraint. And motherhood, especially early motherhood, often determines what kind of life women can build. Pregnancy and childbirth sit at the heart of these patterns. Goldin does not write about labor units or obstetric risk. She writes about time, incentives, and systems. Yet her work helps clinicians see the broader context in which pregnant women make decisions and experience care.

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1. Pregnancy is shaped by the economics of time, not just biology

Goldin’s most influential insight is that the heart of gender inequality lies not only in discrimination but also in the unequal distribution of time. Women do more unpaid caregiving than men. Women’s careers are more likely to be interrupted. Women face what she calls “greedy jobs,” roles that demand unpredictable hours and penalize flexibility. Pregnancy sits inside this landscape. Many women delay childbearing not because they want to, but because the timing of pregnancy is constrained by education, employment expectations, and economic risk. When clinicians see pregnancy as a purely biological event, they overlook the structural pressures that shape when and how women become mothers. Goldin helps us understand that reproductive choices occur inside economic realities, not outside them.

2. The motherhood penalty begins long before birth

Goldin documented that women’s wages begin to diverge from men’s around the arrival of the first child. She called this the “motherhood penalty.” It affects career trajectories, lifetime earnings, and access to leadership roles. The penalty does not start at the baby’s first breath. It begins when women must navigate prenatal appointments around jobs with limited leave, when they worry about losing hours or being seen as unreliable, and when the cost of pregnancy falls disproportionately on them. Obstetric care often extracts time, energy, and financial resources that women struggle to spare. Goldin urges us to see the cumulative effect of these disruptions. Clinicians cannot change national labor policy, but they can recognize that each appointment, each instruction, and each delay interacts with a woman’s economic stability.

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3. Inequality deepens when systems assume a full-time caregiver

Goldin showed that modern workplaces were built on an outdated model of the household, one where one partner worked full time while the other stayed home. Pregnancy care sometimes mirrors this assumption. Women are expected to attend frequent visits, modify schedules, arrange childcare for other children, and comply with recommendations that take time and flexibility. When a woman cannot conform, she may be labeled noncompliant or disengaged. Goldin would argue that the problem is not the woman. It is the system. Obstetrics becomes more humane when clinicians ask, “What requirements are we placing on her, and are they realistic.” Acknowledging these constraints does not lower standards. It increases fairness.

4. Choice is real, but it is not free

Goldin resisted simplistic narratives about women choosing differently from men. She showed that choices are shaped by opportunities, information, and systemic barriers. In obstetrics, women often face decisions framed as individual preferences. Induction or waiting. Epidural or no epidural. VBAC or repeat cesarean. But each decision is shaped by the woman’s job security, her access to support, her insurance coverage, and her economic vulnerability. A woman may opt for induction not because it is medically preferable but because she cannot afford unpredictability. Another may avoid a recommended intervention because leave from work is limited. Goldin teaches clinicians to see the economic scaffolding behind what appear to be personal decisions. Respecting autonomy requires understanding the pressures that shape it.

5. The narrative of “having it all” obscures the cost of doing it all

Goldin’s research dismantled the myth that progress for women is linear. Gains in education and employment do not eliminate the structural tension between paid work and caregiving. Pregnancy often intensifies this tension. Women are told to plan their births around medical advice while simultaneously being expected to remain fully productive at work. They must perform flexibility in systems that do not offer it. Goldin explains why this conflict feels so exhausting. The system expects women to stretch, not the institutions around them. Obstetrics can play a role in easing this burden. When clinicians offer scheduling options, reduce unnecessary visits, and use telehealth strategically, they acknowledge that supporting pregnancy also means supporting women’s economic lives.

6. Better outcomes depend on understanding the life cycle, not just the pregnancy

A central theme in Goldin’s work is that women’s outcomes cannot be understood by looking at single moments. They must be viewed across the life cycle. Pregnancy is one chapter in a long economic story. A traumatic birth may disrupt employment for years. A respectful birth may strengthen a woman’s sense of agency. Postpartum recovery affects return to work, breastfeeding influences time use, and childcare availability determines whether paid employment is possible. Goldin helps clinicians see that obstetric care is never isolated. It intersects with a woman’s future earning potential, mental health, and long-term autonomy. When clinicians recognize this, their counseling becomes more contextual and more compassionate.

7. The ethics of obstetric care include acknowledging the economics of women’s lives

Goldin never studied obstetrics, yet her insights resonate with the ethical responsibilities of the field. Caring for pregnant women means understanding the forces that shape their decisions. It means recognizing the constraints that make certain recommendations difficult. It means naming the structural inequalities that burden women rather than assuming they arise from individual preference. Goldin’s work calls clinicians to humility and awareness. Pregnancy is not only a biological event. It is an economic transition, a social shift, and a restructuring of time. Obstetric care becomes more ethical when it honors these realities and adapts to them. Goldin’s enduring message is that understanding women’s lives requires looking beyond the clinic and into the systems that shape their choices.

Reflection

Claudia Goldin teaches us that pregnancy exists inside an economic landscape that shapes every decision women make. Her insights challenge clinicians to ask whether they see the full reality of the women they care for. When obstetrics acknowledges the pressures of time, work, and inequality, it becomes not only safer but more just. Goldin leaves us with a question. Are we caring for pregnancy alone, or are we caring for the woman who must carry its consequences across her entire life.

Here is everything you need to know, including when to see an eye doctor and how to handle eye makeup when your eyes are at their most sensitive.

The Conversation Nobody Is Having

Think about everything your ObGyn discusses during prenatal care. Weight. Blood pressure. Glucose screening. Genetic testing. Exercise. Diet. Sleep position. Dental visits.

Now think about your eyes.

Nothing.

Your ObGyn almost certainly said nothing about your eyes.

This is a remarkable gap. Pregnancy produces real, measurable changes in your eyes. So do the fertility medications that many women take to get pregnant in the first place. Vision can fluctuate. Eyes dry out. Contact lenses stop fitting. And in rare cases, visual symptoms can be the first sign of a serious complication like preeclampsia.

Yet no one brings it up. Not at the first prenatal visit. Not at any prenatal visit. The topic does not appear on standard prenatal counseling checklists. Most ObGyn residency training covers ocular emergencies (scotomas in preeclampsia, for example) but says almost nothing about the routine eye changes that affect millions of pregnant women every year.

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The result is predictable. Women notice their vision is different. They wonder if something is wrong. They Google at 2 a.m. They either worry unnecessarily about something benign, or they ignore a symptom that actually needed attention.

A woman’s focus during pregnancy (so to speak) is somewhere else entirely. That is understandable. But it does not mean her eyes should be forgotten.

It Starts Before Pregnancy: Fertility Medications and Your Eyes

For women undergoing fertility treatment, eye changes can begin before pregnancy even starts.

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Clomiphene citrate (Clomid), the most commonly prescribed fertility medication, has well-documented visual side effects. These include blurred vision, flashing lights, shimmering in the visual field, light sensitivity, and a phenomenon called palinopsia, where afterimages linger longer than normal (4, 5). These effects occur because clomiphene is an estrogen receptor blocker, and estrogen receptors exist in the retina and visual pathways, not just the reproductive system.

Most visual symptoms from clomiphene are mild and resolve when the medication is stopped. But not always. Case reports document patients with visual disturbances persisting years after discontinuing the drug (5). Rare but serious complications include central retinal vein occlusion and optic neuropathy (4, 6).

The prescribing information for clomiphene states clearly that the drug should be discontinued if visual symptoms occur. Yet how many women starting Clomid are told to watch for visual changes? How many know that blurred vision on day three of their Clomid cycle is a recognized side effect and not just fatigue?

Gonadotropin therapy (injectable FSH, used in IVF cycles) has also been associated with ocular changes. IVF treatment increases vascular endothelial growth factor (VEGF) levels, and elevated VEGF has been linked in case reports to retinal complications including retinal detachment and choroidal neovascularization (4). These are rare events, but they underscore the point: fertility treatment affects the eyes, and patients deserve to know that before they start.

The bottom line for women trying to conceive: If you are taking clomiphene or undergoing IVF and you notice any visual changes, blurred vision, flashing lights, shimmering, spots, or lingering afterimages, tell your fertility doctor immediately. Do not assume it is stress or fatigue. It may be a medication effect that requires evaluation.

What you are about to read will change how you walk into your next exam room.

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Why Do Pregnant Woman see an Obstetrician?

Pregnant women seek obstetric care for reasons far more fundamental than scheduling tests or documenting vital signs. They come because they have questions that matter, worries that need interpretation, and physical changes that sometimes require expert diagnosis.

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They come for reassurance, for guidance, and for the kind of compassionate presence that helps them navigate uncertainty. They come because pregnancy is both biological and emotional, and they want a clinician who can hold both with skill.

These expectations define the heart of obstetric practice and are exactly what the next generation of AI-supported care must strengthen rather than diminish.

The Perfect Obstetrician is here

Obstetric Intelligence is creating a clinician whose cognitive reach, precision, and availability far exceed anything medicine has previously known.
Artificial intelligence is not merely inventing a better clinical tool. It is creating a new category of obstetrician. This entity is an AI-supported experienced obstetrician created construct working in continuous partnership with an obstetrician, bringing an exponentially expanded knowledge base, deep analytical capacity, perfect compassion, and round-the-clock availability. Never tired. Reads a cardiotocogram (CTG) or an ultrasound quickly and perfectly.

The question is no longer whether AI will reshape obstetric practice. It already has. The essential task is to understand how this partnership will redefine excellence, safety, and responsibility in maternal-fetal medicine.

The rest of this post is for paid subscribers.

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It has no ICD-10 code.

It cannot be diagnosed by ultrasound.

No laboratory test detects it.

Yet it affects countless women after giving birth.

Many leave the hospital believing they have failed.

Not because their baby was harmed.

Not because they made poor decisions.

Not because their clinicians failed them.

But because their birth did not unfold the way they had imagined.

“I ended up with a cesarean.”

“I couldn’t do it without an epidural.”

“My body failed.”

“I wasn’t strong enough.”

“I didn’t get the birth I wanted.”

These are among the most heartbreaking sentences I hear.

Not because they describe bad medicine.

But because they often describe good medicine viewed through the lens of unrealistic expectations.

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How did we create a culture in which a healthy mother with a healthy baby can still leave believing she failed?

That question deserves far more attention than it receives.

Because I do not believe women are failing birth.

I believe birth culture is failing women.

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Why do so many women experience guilt after medically appropriate births? Why do epidurals, inductions, and cesarean deliveries become symbols of failure rather than evidence of individualized care? And why has childbirth increasingly become something to achieve instead of something to navigate?

In this essay, I argue that modern birth culture has unintentionally transformed childbirth into a performance with winners and losers. It is time to change that narrative.

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It appears in childbirth education, birth plans, social media, books, and even scientific publications. The story is familiar.

An epidural leads to oxytocin.

Oxytocin leads to fetal heart rate abnormalities.

Fetal heart rate abnormalities lead to cesarean delivery.

The conclusion seems obvious.

If the first intervention had never occurred, the cesarean would never have happened.

It is a compelling narrative.

It is also a causal claim.

And causal claims require evidence.

What if we have been asking the wrong question?

What if many so-called cascades of intervention are not caused by the intervention at all?

What if they are instead the consequence of a labor that was already becoming increasingly abnormal?

What if the interventions are simply the visible markers of clinicians recognizing new risks as labor unfolds?

That possibility changes how we interpret research.

It changes how we counsel pregnant patients.

And it changes how we think about one of the most frequently repeated concepts in maternity care.

This article argues that many “cascades of intervention” are better understood as cascades of risk recognition.

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The remainder of this essay explores why sequence is so often mistaken for causation, how confounding by indication shapes obstetric decision making, why observational studies can reinforce misleading narratives, and why distinguishing intervention from risk recognition matters for evidence-based counseling and patient safety.

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Dario Amodei runs Anthropic, one of the largest artificial intelligence companies in the world. On Stripe’s “A Cheeky Pint” podcast, in conversation with John Collison, he repeated something Nobel Prize winning biologists had told him. They said they would only see the top 1 percent of doctors. For the other 99 percent, a large language model gives bett…

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“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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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.

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