American Journal of Obstetrics and Gynecology, 2021
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
THE ELECTORAL MAP OF 2000-WITH ITS COASTAL BLUE EDGES AND POINtillist urban centers set against g... more THE ELECTORAL MAP OF 2000-WITH ITS COASTAL BLUE EDGES AND POINtillist urban centers set against great swaths of red-told many political and economic stories. Attitudes toward rural life often reveal a complex mixture of affection and disdain, ideas about neighborliness and isolation, simplicity and provincialism. In his recent essay, "One Nation, Slightly Divisible," David Brooks argues that the differences between rural and urban America may be merely superficial, exemplified in consumer preferences such as Wal-Mart vs Pottery Barn. 1 Although I agree with his assertion that the two locales possess unique "sensibilities," there are important differences in rural vs urban health care. While 20% of Americans live in rural areas, only 9% of the nation's physicians practice there. Poverty-a principal health risk factor in any geographic locale-is more prevalent in rural areas and is often related to increased rates of chronic disease and greater numbers of uninsured citizens. 2 Rural residents have fewer physicians and nurses per capita and increased transportation barriers; they visit a physician less often and later in the course of their illness than do urban residents. 2 This issue of MSJAMA explores the question of whether there are two US health care delivery systems, one urban and one rural. Differences between urban and rural health care exist on a continuum defined by many variables. Susan Blumenthal and Jessica Kagen provide an epidemiologic background in which to consider important differences and markers between rural and urban health. Hilda Heady explores some of the monetary inequities embodied in rural vs urban reimbursement policies. Terry Meden and colleagues describe how distance from a tertiary care center may be related to decisions about mastectomy for rural women with stages I and II breast cancer. Although Roe vs Wade made abortion legal in the United States, this right may be moot in many rural settings. Trude Bennett explores some of these barriers to prenatal care, family planning, surgical contraception, and other reproductive health care services in rural areas. To address the chronic geographic maldistribution of physicians, Howard Rabinowitz and Nina Paynter outline the constructs that inform medical students' decision to become generalists or specialists and correlatively to practice in a rural vs an urban setting. These inequities in rural vs urban health care delivery are based in structural, economic, and cultural differences. Through increased awareness, research, education, and preventive public health measures, congress, and ultimately communities and the health care providers who serve them, may begin to lessen the degrees of difference.
Current practices in the U.S. health care industry drive climate change. This review summarizes t... more Current practices in the U.S. health care industry drive climate change. This review summarizes the vast research on the negative health effects of the climate crisis on patients as relevant to obstetrics and gynecology. We further propose solutions to decarbonize operating rooms, labor and delivery units, and nurseries and neonatal intensive care units through evidence-based reduction in our single-use supply, energy, and water, as well as anesthetic gases and appropriate waste sorting.
American Journal of Obstetrics and Gynecology, 2020
C oronavirus disease 2019 (COVID-19), caused by the virulent severe acute respiratory syndrome co... more C oronavirus disease 2019 (COVID-19), caused by the virulent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first emerged as a human disease in December 2019 in Hubei province, China. 1 It spread rapidly throughout the world and was declared a pandemic by the World Health Organization on March 11, 2020.
American Journal of Physiology-Gastrointestinal and Liver Physiology, 2001
This in vitro study investigated the relationship between rabbit colonic muscularis mucosae motor... more This in vitro study investigated the relationship between rabbit colonic muscularis mucosae motor activity and changes in transmucosal potential difference. Spontaneous muscle contractions and potential difference oscillations occurred independently and were not neurally driven. ACh and histamine directly stimulated the muscularis mucosae, but their mucosal effects were largely indirect, suggesting that muscularis mucosae contractions promote epithelial secretion. 1,1-Dimethyl-4-phenyl-piperazinium iodide and vasoactive intestinal polypeptide induced large potential difference changes but small muscularis mucosae contractions, demonstrating mucosal secretion without significant muscle activity. Lowered intraluminal pH directly stimulated the muscle, whereas a bile salt-lipid mixture evoked TTX- and atropine-sensitive increases in its contractile activity. Increased intraluminal pressure and hypertonic luminal perfusion did not elicit muscularis mucosae excitation. Thus under basal c...
A s we read the final writings of civil rights activist John Lewis, two excerpts struck us: “I ur... more A s we read the final writings of civil rights activist John Lewis, two excerpts struck us: “I urge you to answer the highest calling of your heart and stand up for what you truly believe” and “continue to build union between movements stretching across the globe.”1 The collective mission of everyone in obstetrics and gynecology is to advance women’s health. However, structural and institutional inequities in our hospital corridors, operating rooms, clinics, conference rooms, and research laboratories limit health care access, restrict educational opportunities, and cause poor health outcomes for the women we vowed to serve. We as a specialty must heed John Lewis’s call to stand up for what we truly believe—that the only way to advance women’s health is by attaining both gender and racial equity—and to highlight issues facing all women, including transgender, nonbinary, and women of color. Vital to achieving equity is remembering the mission of obstetrics and gynecology —to advance women’s health through education, practice, research, and advocacy. To advance women’s health through education, we must create cultures and systems that ensure everyone’s physical and psychological safety. Although little research has been conducted specifically in obstetrics and gynecology, discrimination and harassment are persistent in health care, as noted in studies reporting that up to 76% of women experienced discrimination,2 nearly 50% of female medical students experienced harassment,3 65.1% of female surgical residents experienced gender discrimination, and 19.9% experienced sexual harassment.4 Moreover, women and Black, Indigenous, and People of Color (BIPOC, a term that emphasizes the historic oppression of Black and Indigenous people) experienced a “disproportionate burden of the mistreatment reported in medical schools,”5 and 70% of Black surgical residents experienced discrimination based on race.4 A culture of safety is essential for educational success, worker safety, and patient safety.3 Harassment and discrimination based on gender, race, ethnicity, or sexual orientation violate safety. Eliminating such mistreatment is vital to our ability to train the next generation of obstetrics and gynecology specialists. To advance women’s health through practice, we must address pay inequity in obstetrics and gynecology. Our field is notable for the fact that 58% of obstetrics and gynecology specialists and 83.5% of obstetrics and gynecology residents are female, and we have one of the highest representations of BIPOC physicians6 (18.4% in 2016). However, women and BIPOC professionals receive less compensation than their White male colleagues. In 2016, female obstetrics and gynecology specialists in academia were paid $36,000 less per year than their male counterparts,7 and women in private practice were paid $100,000 less per year than men.8,9 Moreover, a $100,000 pay gap exists between White male physicians and Black female physicians across all specialties,10 and a $50,000 pay gap exists between White and Black physicians.11 Over the length of a physician’s career, such inequity can lead to a wealth gap of up to $6 million, Jane van Dis is from the Department of Obstetrics and Gynecology, USC Verdugo Hills, Glendale, California. Sarah England is from the Department of ObGyn, Washington University School of Medicine in St. Louis, St. Louis, Missouri; email: [email protected].
Journal of the American Medical Women's Association, 2003
Tower 3, we are within 15 knots of your location, stand by for immediate update. MALE VOICE Roger... more Tower 3, we are within 15 knots of your location, stand by for immediate update. MALE VOICE Roger that, Delta. Are you seeing anything up there? PILOT VOICE Negative, Tower. All is clear. No sign of an object yet. EXT. EARTH'S ORBIT-SPACE 1 1 The blue, marvelous, and impeccable glow from the planet catches our eyes. As we watch the seemingly motionless revolutions, the voices begin to interrupt the peaceful, serene silence. MALE VOICE Delta, are you picking up that signal? The pilot gathers information. 8. SLOW FOLLOW We see workers out in the yard. Slaving away at carrying metal, repairing machinery, and enduring the already hellish heat. Jack makes his way to the main office. INT. MAIN OFFICE-MORNING 9 9 He walks in and sets his lunch pale down in a secure box. A small digital screen appears and Jack locks the box. His lunch is safe. The BOSS MAN (40's) approaches him. Smiling and holding a cup of coffee. BOSS MAN Jack, how are you? Jack speaks in kind voice. JACK Mornin, sir. How's the coffee? BOSS MAN Great, there's a fresh pot on in the lounge. Want me to get you a cup? JACK No, no, but thank you. The boss smiles. BOSS MAN We have a solar battery that needs installing out at site 4. Would you mind going with Jose and Terry to install it? JACK No, not at all. BOSS MAN Good man. I'll go tell them, and Jack. JACK Yes, sir? BOSS MAN Use your company card and buy you boys some water or something cold. Supposed to be a hot one today. 9. 10. JACK Welcome to Texas. JOSE The temperature always like this? JACK I'm afraid so. Jack retrieves a voltage meter. JOSE Man, if I were mother nature. I would at least provide a cool gentle breeze. JACK You sure you wouldn't freeze the entire place over? JOSE Ah, nah! JACK Don't lie, Jose. Jose laughs and speaks sarcastically. JOSE Cool us down, wouldn't it? JACK You gotta point. He finishes checking a wire connection and backs away. JACK (cont'd) Alright, the main O.S has been loaded in, all the circuits are in order, and the wires are all nice and tight. Ready for a test. JOSE Okay. Jack prepares the battery. Jose and the other men begin to hook up cables and wires into the both the converters and the battery. Soon, large plastic covered wires cover the land and connect to a small power grid. Jack checks the system and activates it. 11. The place is basically your typical bar. A filled room with truckers, bikers, workers, and other types. There's pretty women, hard ass men, and tough big boys. Jack sits on the bar and drinks a Coors. A nice bartender named ALMA (30's) walks over to him. ALMA Jack, how we doin? JACK Pretty good, Al. ALMA Need another one? Jack takes a quick swig of the remaining beer in the bottle and hands her it. JACK When you get a chance. She smiles and pulls a cold one out from a fridge. ALMA What's your plans for this weekend? Anything exciting? Jack sips his beer. JACK Nothing really. What's your plans? ALMA Well... nothing either. JACK Sounds good. She laughs. ALMA When you gonna get out of this place? Jack looks at her, inquisitive like. JACK I'm sorry, Alma I paid my tabs and that incident in the bathroom wasn't me. Alma smiles and laughs.
Healthcare providers and staff should ensure they create a non-judgmental, welcoming and inclusiv... more Healthcare providers and staff should ensure they create a non-judgmental, welcoming and inclusive environment for their patients.
JAMA: The Journal of the American Medical Association, 2003
Jane van Dis I KNOCKED SOFTLY. THE ROOM WAS DARK AS I SLIPPED AROUND THE SAGEgreen door, save for... more Jane van Dis I KNOCKED SOFTLY. THE ROOM WAS DARK AS I SLIPPED AROUND THE SAGEgreen door, save for light sifting through the metal blinds and the bluegray glow of the screen as it showed off its sandy sonographic images of the abdominal wall, placenta, and fetus. The obstetrician moved the slickened transducer across the woman's abdomen, pointing out landmarks and serving as guide to this anatomical museum suspended in amnion. "This is baby's kidney. And over here we have baby's stomach." Baby? Talking in the hallway out of the patient's earshot, my attending remarked, "The fetus appears on exam to be healthy." Although the proper use of "baby" vs "fetus" is generally not a part of formal obstetric training for medical students, maternal-fetal ethics instruction is a component of medical and resident education. A 1994 study found that the top 2 issues of interest in obstetric ethics education were "abortion" and "maternal-fetal conflict." 1 Although obstetricians rarely encounter ethical dilemmas like courtordered cesarean deliveries or pregnant patients refusing lifesustaining blood transfusions, unplanned pregnancy and drug and alcohol use during pregnancy are common occurrences. 2,3 Thus it is not surprising that the pregnant woman is a focus of complex cultural expectations, moral obligations, and legal rights. This issue of MSJAMA addresses some of the constructs and tensions in the maternal-fetal relationship. The maternal-fetal relationship is the subject of intense public policy debates. Lisa Harris and Lynn Paltrow report on courts' opinions regarding the prosecution of pregnant women for potential fetal harm. Nathan Stormer explores how contemporary biomedical images of the fetus are changing public perception of the pregnant body and fetus. Amy Salisbury and colleagues describe how researchers are attempting to measure maternal-fetal attachment and its possible implications for fetal and maternal health during pregnancy. Although fundamental and seemingly unalterable, the definition of the maternal-fetal relationship is undergoing a rapid evolution of context, in part due to advances in imaging, prenatal diagnostics, genetic screening, and fetal surgery. While the formal principles of autonomy and beneficence provide an initial point from which to analyze the sometimes conflicting needs of the pregnant woman and her fetus, the maternal-fetal relationship is becoming too complex to rely on simple algorithms. As medical technology and innovation advance, and as cultural and political dialogues continue to influence the patient-physician encounter, physicians' knowledge of and participation in ethical dialogue on the maternal-fetal relationship will continue to be an increasingly important part of obstetric care.
American Journal of Obstetrics and Gynecology, 2021
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
THE ELECTORAL MAP OF 2000-WITH ITS COASTAL BLUE EDGES AND POINtillist urban centers set against g... more THE ELECTORAL MAP OF 2000-WITH ITS COASTAL BLUE EDGES AND POINtillist urban centers set against great swaths of red-told many political and economic stories. Attitudes toward rural life often reveal a complex mixture of affection and disdain, ideas about neighborliness and isolation, simplicity and provincialism. In his recent essay, "One Nation, Slightly Divisible," David Brooks argues that the differences between rural and urban America may be merely superficial, exemplified in consumer preferences such as Wal-Mart vs Pottery Barn. 1 Although I agree with his assertion that the two locales possess unique "sensibilities," there are important differences in rural vs urban health care. While 20% of Americans live in rural areas, only 9% of the nation's physicians practice there. Poverty-a principal health risk factor in any geographic locale-is more prevalent in rural areas and is often related to increased rates of chronic disease and greater numbers of uninsured citizens. 2 Rural residents have fewer physicians and nurses per capita and increased transportation barriers; they visit a physician less often and later in the course of their illness than do urban residents. 2 This issue of MSJAMA explores the question of whether there are two US health care delivery systems, one urban and one rural. Differences between urban and rural health care exist on a continuum defined by many variables. Susan Blumenthal and Jessica Kagen provide an epidemiologic background in which to consider important differences and markers between rural and urban health. Hilda Heady explores some of the monetary inequities embodied in rural vs urban reimbursement policies. Terry Meden and colleagues describe how distance from a tertiary care center may be related to decisions about mastectomy for rural women with stages I and II breast cancer. Although Roe vs Wade made abortion legal in the United States, this right may be moot in many rural settings. Trude Bennett explores some of these barriers to prenatal care, family planning, surgical contraception, and other reproductive health care services in rural areas. To address the chronic geographic maldistribution of physicians, Howard Rabinowitz and Nina Paynter outline the constructs that inform medical students' decision to become generalists or specialists and correlatively to practice in a rural vs an urban setting. These inequities in rural vs urban health care delivery are based in structural, economic, and cultural differences. Through increased awareness, research, education, and preventive public health measures, congress, and ultimately communities and the health care providers who serve them, may begin to lessen the degrees of difference.
Current practices in the U.S. health care industry drive climate change. This review summarizes t... more Current practices in the U.S. health care industry drive climate change. This review summarizes the vast research on the negative health effects of the climate crisis on patients as relevant to obstetrics and gynecology. We further propose solutions to decarbonize operating rooms, labor and delivery units, and nurseries and neonatal intensive care units through evidence-based reduction in our single-use supply, energy, and water, as well as anesthetic gases and appropriate waste sorting.
American Journal of Obstetrics and Gynecology, 2020
C oronavirus disease 2019 (COVID-19), caused by the virulent severe acute respiratory syndrome co... more C oronavirus disease 2019 (COVID-19), caused by the virulent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first emerged as a human disease in December 2019 in Hubei province, China. 1 It spread rapidly throughout the world and was declared a pandemic by the World Health Organization on March 11, 2020.
American Journal of Physiology-Gastrointestinal and Liver Physiology, 2001
This in vitro study investigated the relationship between rabbit colonic muscularis mucosae motor... more This in vitro study investigated the relationship between rabbit colonic muscularis mucosae motor activity and changes in transmucosal potential difference. Spontaneous muscle contractions and potential difference oscillations occurred independently and were not neurally driven. ACh and histamine directly stimulated the muscularis mucosae, but their mucosal effects were largely indirect, suggesting that muscularis mucosae contractions promote epithelial secretion. 1,1-Dimethyl-4-phenyl-piperazinium iodide and vasoactive intestinal polypeptide induced large potential difference changes but small muscularis mucosae contractions, demonstrating mucosal secretion without significant muscle activity. Lowered intraluminal pH directly stimulated the muscle, whereas a bile salt-lipid mixture evoked TTX- and atropine-sensitive increases in its contractile activity. Increased intraluminal pressure and hypertonic luminal perfusion did not elicit muscularis mucosae excitation. Thus under basal c...
A s we read the final writings of civil rights activist John Lewis, two excerpts struck us: “I ur... more A s we read the final writings of civil rights activist John Lewis, two excerpts struck us: “I urge you to answer the highest calling of your heart and stand up for what you truly believe” and “continue to build union between movements stretching across the globe.”1 The collective mission of everyone in obstetrics and gynecology is to advance women’s health. However, structural and institutional inequities in our hospital corridors, operating rooms, clinics, conference rooms, and research laboratories limit health care access, restrict educational opportunities, and cause poor health outcomes for the women we vowed to serve. We as a specialty must heed John Lewis’s call to stand up for what we truly believe—that the only way to advance women’s health is by attaining both gender and racial equity—and to highlight issues facing all women, including transgender, nonbinary, and women of color. Vital to achieving equity is remembering the mission of obstetrics and gynecology —to advance women’s health through education, practice, research, and advocacy. To advance women’s health through education, we must create cultures and systems that ensure everyone’s physical and psychological safety. Although little research has been conducted specifically in obstetrics and gynecology, discrimination and harassment are persistent in health care, as noted in studies reporting that up to 76% of women experienced discrimination,2 nearly 50% of female medical students experienced harassment,3 65.1% of female surgical residents experienced gender discrimination, and 19.9% experienced sexual harassment.4 Moreover, women and Black, Indigenous, and People of Color (BIPOC, a term that emphasizes the historic oppression of Black and Indigenous people) experienced a “disproportionate burden of the mistreatment reported in medical schools,”5 and 70% of Black surgical residents experienced discrimination based on race.4 A culture of safety is essential for educational success, worker safety, and patient safety.3 Harassment and discrimination based on gender, race, ethnicity, or sexual orientation violate safety. Eliminating such mistreatment is vital to our ability to train the next generation of obstetrics and gynecology specialists. To advance women’s health through practice, we must address pay inequity in obstetrics and gynecology. Our field is notable for the fact that 58% of obstetrics and gynecology specialists and 83.5% of obstetrics and gynecology residents are female, and we have one of the highest representations of BIPOC physicians6 (18.4% in 2016). However, women and BIPOC professionals receive less compensation than their White male colleagues. In 2016, female obstetrics and gynecology specialists in academia were paid $36,000 less per year than their male counterparts,7 and women in private practice were paid $100,000 less per year than men.8,9 Moreover, a $100,000 pay gap exists between White male physicians and Black female physicians across all specialties,10 and a $50,000 pay gap exists between White and Black physicians.11 Over the length of a physician’s career, such inequity can lead to a wealth gap of up to $6 million, Jane van Dis is from the Department of Obstetrics and Gynecology, USC Verdugo Hills, Glendale, California. Sarah England is from the Department of ObGyn, Washington University School of Medicine in St. Louis, St. Louis, Missouri; email: [email protected].
Journal of the American Medical Women's Association, 2003
Tower 3, we are within 15 knots of your location, stand by for immediate update. MALE VOICE Roger... more Tower 3, we are within 15 knots of your location, stand by for immediate update. MALE VOICE Roger that, Delta. Are you seeing anything up there? PILOT VOICE Negative, Tower. All is clear. No sign of an object yet. EXT. EARTH'S ORBIT-SPACE 1 1 The blue, marvelous, and impeccable glow from the planet catches our eyes. As we watch the seemingly motionless revolutions, the voices begin to interrupt the peaceful, serene silence. MALE VOICE Delta, are you picking up that signal? The pilot gathers information. 8. SLOW FOLLOW We see workers out in the yard. Slaving away at carrying metal, repairing machinery, and enduring the already hellish heat. Jack makes his way to the main office. INT. MAIN OFFICE-MORNING 9 9 He walks in and sets his lunch pale down in a secure box. A small digital screen appears and Jack locks the box. His lunch is safe. The BOSS MAN (40's) approaches him. Smiling and holding a cup of coffee. BOSS MAN Jack, how are you? Jack speaks in kind voice. JACK Mornin, sir. How's the coffee? BOSS MAN Great, there's a fresh pot on in the lounge. Want me to get you a cup? JACK No, no, but thank you. The boss smiles. BOSS MAN We have a solar battery that needs installing out at site 4. Would you mind going with Jose and Terry to install it? JACK No, not at all. BOSS MAN Good man. I'll go tell them, and Jack. JACK Yes, sir? BOSS MAN Use your company card and buy you boys some water or something cold. Supposed to be a hot one today. 9. 10. JACK Welcome to Texas. JOSE The temperature always like this? JACK I'm afraid so. Jack retrieves a voltage meter. JOSE Man, if I were mother nature. I would at least provide a cool gentle breeze. JACK You sure you wouldn't freeze the entire place over? JOSE Ah, nah! JACK Don't lie, Jose. Jose laughs and speaks sarcastically. JOSE Cool us down, wouldn't it? JACK You gotta point. He finishes checking a wire connection and backs away. JACK (cont'd) Alright, the main O.S has been loaded in, all the circuits are in order, and the wires are all nice and tight. Ready for a test. JOSE Okay. Jack prepares the battery. Jose and the other men begin to hook up cables and wires into the both the converters and the battery. Soon, large plastic covered wires cover the land and connect to a small power grid. Jack checks the system and activates it. 11. The place is basically your typical bar. A filled room with truckers, bikers, workers, and other types. There's pretty women, hard ass men, and tough big boys. Jack sits on the bar and drinks a Coors. A nice bartender named ALMA (30's) walks over to him. ALMA Jack, how we doin? JACK Pretty good, Al. ALMA Need another one? Jack takes a quick swig of the remaining beer in the bottle and hands her it. JACK When you get a chance. She smiles and pulls a cold one out from a fridge. ALMA What's your plans for this weekend? Anything exciting? Jack sips his beer. JACK Nothing really. What's your plans? ALMA Well... nothing either. JACK Sounds good. She laughs. ALMA When you gonna get out of this place? Jack looks at her, inquisitive like. JACK I'm sorry, Alma I paid my tabs and that incident in the bathroom wasn't me. Alma smiles and laughs.
Healthcare providers and staff should ensure they create a non-judgmental, welcoming and inclusiv... more Healthcare providers and staff should ensure they create a non-judgmental, welcoming and inclusive environment for their patients.
JAMA: The Journal of the American Medical Association, 2003
Jane van Dis I KNOCKED SOFTLY. THE ROOM WAS DARK AS I SLIPPED AROUND THE SAGEgreen door, save for... more Jane van Dis I KNOCKED SOFTLY. THE ROOM WAS DARK AS I SLIPPED AROUND THE SAGEgreen door, save for light sifting through the metal blinds and the bluegray glow of the screen as it showed off its sandy sonographic images of the abdominal wall, placenta, and fetus. The obstetrician moved the slickened transducer across the woman's abdomen, pointing out landmarks and serving as guide to this anatomical museum suspended in amnion. "This is baby's kidney. And over here we have baby's stomach." Baby? Talking in the hallway out of the patient's earshot, my attending remarked, "The fetus appears on exam to be healthy." Although the proper use of "baby" vs "fetus" is generally not a part of formal obstetric training for medical students, maternal-fetal ethics instruction is a component of medical and resident education. A 1994 study found that the top 2 issues of interest in obstetric ethics education were "abortion" and "maternal-fetal conflict." 1 Although obstetricians rarely encounter ethical dilemmas like courtordered cesarean deliveries or pregnant patients refusing lifesustaining blood transfusions, unplanned pregnancy and drug and alcohol use during pregnancy are common occurrences. 2,3 Thus it is not surprising that the pregnant woman is a focus of complex cultural expectations, moral obligations, and legal rights. This issue of MSJAMA addresses some of the constructs and tensions in the maternal-fetal relationship. The maternal-fetal relationship is the subject of intense public policy debates. Lisa Harris and Lynn Paltrow report on courts' opinions regarding the prosecution of pregnant women for potential fetal harm. Nathan Stormer explores how contemporary biomedical images of the fetus are changing public perception of the pregnant body and fetus. Amy Salisbury and colleagues describe how researchers are attempting to measure maternal-fetal attachment and its possible implications for fetal and maternal health during pregnancy. Although fundamental and seemingly unalterable, the definition of the maternal-fetal relationship is undergoing a rapid evolution of context, in part due to advances in imaging, prenatal diagnostics, genetic screening, and fetal surgery. While the formal principles of autonomy and beneficence provide an initial point from which to analyze the sometimes conflicting needs of the pregnant woman and her fetus, the maternal-fetal relationship is becoming too complex to rely on simple algorithms. As medical technology and innovation advance, and as cultural and political dialogues continue to influence the patient-physician encounter, physicians' knowledge of and participation in ethical dialogue on the maternal-fetal relationship will continue to be an increasingly important part of obstetric care.
Uploads
Papers by Jane van Dis