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Individuals require access to safe, legal abortion. Abortion, although legal, is increasingly out of reach because of numerous restrictions imposed by the government that target patients seeking abortion and their health care practitioners. Insurance coverage restrictions, which take many forms, constitute a substantial barrier to abortion access and increase reproductive health inequities. Adolescents, people of color, those living in rural areas, those with low incomes, and incarcerated people can face disproportionate effects of restrictions on abortion access. Stigma and fear of violence may be less tangible than legislative and financial restrictions, but are powerful barriers to abortion provision nonetheless. The American College of Obstetricians and Gynecologists, along with other medical organizations, opposes such interference with the patient-clinician relationship, affirming the importance of this relationship in the provision of high-quality medical care. This revision includes updates based on new restrictions and litigation related to abortion.

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained, even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.

Pelvic organ prolapse (POP) is a common, benign condition in women. For many women, it can cause vaginal bulge and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction, which may adversely affect quality of life. Women in the United States have a 13% lifetime risk of undergoing surgery for POP. Although POP can occur in younger women, the peak incidence of POP symptoms is in women aged 70 to 79 years. Given the aging population in the United States, it is anticipated that by 2050 the number of women experiencing POP will increase by approximately 50%. The purpose of this joint document of the American College of Obstetricians and Gynecologists and the American Urogynecologic Society is to review information on the current understanding of POP in women and to outline guidelines for diagnosis and management that are consistent with the best available scientific evidence.

A nationwide questionnaire survey about community-acquired infection of coronavirus disease 2019 (COVID-19) was conducted in July 2020 to identify the characteristics of and measures taken by Japanese medical facilities providing maternity services. A case-control study was conducted by including medical facilities with (Cases) and without (Control) community-acquired infection of COVID-19. Responses from 711 hospitals and 707 private clinics were assessed (72% of all hospital and 59% all private clinics provided maternity service in Japan). Seventy-five COVID-19-positive pregnant women were treated in 52 facilities. Community-acquired infection was reported in 4.1% of the facilities. Of these, 95% occurred in the hospital. Nine patients developed a community-acquired infection in the maternity ward or obstetric department. Variables that associated with community-acquired infection of COVID-19 (adjusted odds ratio [95% confidence interval]) were found to be state of emergency prefecture (4.93 [2.17–11.16]), PCR test for SARS-CoV-2 on admission (2.88 [1.59–5.24]), and facility that cannot treat COVID-19 positive patients (0.34 [0.14–0.82]). In conclusion, community-acquired infection is likely to occur in large hospitals that treat a higher number of patients than private clinics do, regardless of the preventive measures used.

Human papillomavirus (HPV) causes significant morbidity and mortality in women and men. The HPV vaccine significantly reduces the incidence of anogenital cancer and genital warts in women and in men. Human papillomavirus vaccines are among the most effective vaccines available worldwide, with unequivocal data demonstrating greater than 99% efficacy when administered to women who have not been exposed to that particular type of HPV. Obstetrician-gynecologists and other health care professionals should strongly recommend HPV vaccination to eligible patients and stress the benefits and safety of the HPV vaccine. Further, obstetrician-gynecologists are encouraged to stock and administer HPV vaccines in their offices when feasible. Ideally, the HPV vaccine should be given in early adolescence because vaccination is most effective before exposure to HPV through sexual activity. Unvaccinated women age 26 years and younger should receive the HPV vaccine series regardless of sexual activity, prior exposure to HPV, or sexual orientation. The HPV vaccine is now licensed in the United States for women and men through age 45 years. For some women aged 27-45 years who are previously unvaccinated, obstetrician-gynecologists and other health care professionals may use shared clinical decision making regarding HPV vaccination, considering the patient's risk for acquisition of a new HPV infection and whether the HPV vaccine may provide benefit.

Objective: Hypertensive disorder of pregnancy (HDP) is a major cause of maternal death. The goal of this study was to investigate factors associated with maternal death due to HDP.Study design: HDP...

Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.

To make recommendations for saving mothers' lives, issues related to maternal deaths including diseases, causes, treatments, and hospital and regional systems are analyzed by the Maternal Death Exploratory Committee in Japan. In this report, we present ten clinical important recommendations based on the analysis of maternal deaths between 2010 and 2014 in Japan.

This document builds upon recommendations from peer organizations and outlines a process for identifying maternal cases that should be reviewed. Severe maternal morbidity is associated with a high rate of preventability, similar to that of maternal mortality. It also can be considered a near miss for maternal mortality because without identification and treatment, in some cases, these conditions would lead to maternal death. Identifying severe morbidity is, therefore, important for preventing such injuries that lead to mortality and for highlighting opportunities to avoid repeat injuries. The two-step screen and review process described in this document is intended to efficiently detect severe maternal morbidity in women and to ensure that each case undergoes a review to determine whether there were opportunities for improvement in care. Like cases of maternal mortality, cases of severe maternal morbidity merit quality review. In the absence of consensus on a comprehensive list of conditions that represent severe maternal morbidity, institutions and systems should either adopt an existing screening criteria or create their own list of outcomes that merit review.

Interpregnancy care aims to maximize a woman's level of wellness not just in between pregnancies and during subsequent pregnancies, but also along her life course. Because the interpregnancy period is a continuum for overall health and wellness, all women of reproductive age who have been pregnant regardless of the outcome of their pregnancies (ie, miscarriage, abortion, preterm, full-term delivery), should receive interpregnancy care as a continuum from postpartum care. The initial components of interpregnancy care should include the components of postpartum care, such as reproductive life planning, screening for depression, vaccination, managing diabetes or hypertension if needed, education about future health, assisting the patient to develop a postpartum care team, and making plans for long-term medical care. In women with chronic medical conditions, interpregnancy care provides an opportunity to optimize health before a subsequent pregnancy. For women who will not have any future pregnancies, the period after pregnancy also affords an opportunity for secondary prevention and improvement of future health.

Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrial-myometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often requires blood transfusion. Although ultrasound evaluation is important, the absence of ultrasound findings does not preclude a diagnosis of placenta accreta spectrum; thus, clinical risk factors remain equally important as predictors of placenta accreta spectrum by ultrasound findings. There are several risk factors for placenta accreta spectrum. The most common is a previous cesarean delivery, with the incidence of placenta accreta spectrum increasing with the number of prior cesarean deliveries. Antenatal diagnosis of placenta accreta spectrum is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor or bleeding and with avoidance of placental disruption. The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. In addition, established infrastructure and strong nursing leadership accustomed to managing high-level postpartum hemorrhage should be in place, and access to a blood bank capable of employing massive transfusion protocols should help guide decisions about delivery location.

Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.

To clarify the clinical risk factors associated with poor neonatal outcomes due to umbilical cord prolapse (UCP).A postal questionnaire survey was attempted in Japan. The clinical risk factors and managements associated with poor neonatal outcomes were analyzed in cases of UCP treated in Japan.A total of 267 cases of UCP (out of 2 037 460 total deliveries) were analyzed. The rates of intrauterine death, neonatal death and survival with disability were 3.4%, 5.6% and 7.1%, respectively. The multivariate regression analysis for these poor neonatal outcomes revealed that the significant risk factors included a prolapsed amniotic sac (adjusted odds ratio (aOR), 4.49), preterm labor (aOR, 2.99) and replacement of the prolapsed umbilical cord into the uterus (aOR, 2.87). However, UCP that occurred during labor (aOR, 0.28) and emergency cesarean section (aOR, 0.11) were associated with a reduction in the rates of poor outcomes. The interval between the diagnosis of UCP and delivery was significantly longer in the infants with a poor outcome than intact survival (median 30 versus 24 min, p = 0.048).An emergency cesarean section should be carried out immediately to ensure a better outcome for the infant.

Listeriosis is predominantly a foodborne illness, with sporadic and outbreak-related cases tied to consumption of food contaminated with listeria (Listeria monocytogenes). The incidence of listeriosis associated with pregnancy is approximately 13 times higher than in the general population. Maternal infection may present as a nonspecific, flu-like illness with fever, myalgia, backache, and headache, often preceded by diarrhea or other gastrointestinal symptoms. However, fetal and neonatal infections can be severe, leading to fetal loss, preterm labor, neonatal sepsis, meningitis, and death. Pregnant women have been advised to avoid foods with a high risk of contamination with listeria. An exposed pregnant woman with a fever higher than 38.1°C (100.6°F) and signs and symptoms consistent with listeriosis for whom no other cause of illness is known should be simultaneously tested and treated for presumptive listeriosis. No testing, including blood and stool cultures, or treatment is indicated for an asymptomatic pregnant woman who reports consumption of a product that was recalled or implicated during an outbreak of listeria contamination. A pregnant woman who ate a product that was recalled because of listeria contamination and who is afebrile but has signs and symptoms consistent with a minor gastrointestinal or flu-like illness can be managed expectantly.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices and the American College of Obstetricians and Gynecologists recommend that all adults receive an annual influenza vaccine. Influenza vaccination is an essential element of preconception, prenatal, and postpartum care because pregnant women are at an increased risk of serious illness due to seasonal and pandemic influenza. Since 2010, influenza vaccination rates among pregnant women have increased but still need significant improvement. It is particularly important that women who are or will be pregnant during influenza season receive an inactivated influenza vaccine as soon as it is available. It is critically important that all obstetrician-gynecologists and all providers of obstetric care advocate for influenza vaccination, provide the influenza vaccine to their pregnant patients, and receive the influenza vaccine themselves every season. It is imperative that obstetrician-gynecologists, other health care providers, health care organizations, and public health officials continue efforts to improve the rate of influenza vaccination among pregnant women.

The incidence of multifetal gestations in the United States has increased dramatically over the past several decades. The rate of twin births increased 76% between 1980 and 2009, from 18.9 to 33.3 per 1,000 births (). The rate of triplet and higher-order multifetal gestations increased more than 400% during the 1980s and 1990s, peaking at 193.5 per 100,000 births in 1998, followed by a modest decrease to 153.4 per 100,000 births by 2009 (). The increased incidence in multifetal gestations has been attributed to two main factors: 1) a shift toward an older maternal age at conception, when multifetal gestations are more likely to occur naturally, and 2) an increased use of assisted reproductive technology (ART), which is more likely to result in a multifetal gestation ().

In 2011, one in three women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be life-saving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women's access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.

The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends that human papillomavirus (HPV) vaccination routinely be targeted to females and males aged 11 years or 12 years as part of the adolescent immunization platform to help reduce the incidence of anogenital cancers and genital warts associated with HPV infection. The quadrivalent HPV vaccine is approved for use in males and females, whereas the bivalent HPV vaccine is approved for use only in females. For those not vaccinated at the target age, catch-up vaccination is recommended up to age 26 years. The American College of Obstetricians and Gynecologists endorses these recommendations. Although obstetrician-gynecologists are not likely to care for many patients in the initial HPV vaccination target group, they have the opportunity to educate mothers about the importance of vaccinating their children at the recommended age and are critical to vaccinating adolescent girls and young women during the catch-up period. Obstetrician-gynecologists should advise patients and parents that HPV vaccines are most effective in preventing genital cancers when administered before the onset of sexual activity. However, sexually active individuals can receive some benefit from the vaccination because exposure to all HPV types prevented by the vaccines is unlikely in persons aged 13 years through 26 years. Although HPV vaccination in pregnancy is not recommended, neither is routine pregnancy testing before vaccination. Lactating women can receive either HPV vaccine. The need for ongoing cervical cytology screening should be emphasized in all women aged 21 years and older, even those who received HPV vaccination before the onset of sexual activity.

Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.

To clarify the necessity for and problems related to autopsy for determining the cause of maternal death in Japan.Women who died during pregnancy or within a year after delivery were analyzed by the Maternal Death Exploratory Committee between 2012 and 2015 in Japan. Maternal deaths were analyzed to verify the requirement of autopsy in cases in which autopsy was performed and the need for autopsy in cases in which it was not performed.Among the 49 cases performed autopsy, the final diagnosis was compatible with the clinical course in 24 cases, while the autopsy diagnosis was incompatible with the clinical course in 13 cases. In two cases, the final diagnosis was based on the clinical course, but an autopsy could exclude other possible causes. In three cases, no exact cause of maternal death was identified after autopsy. On the other hand, in cases without an autopsy, the final diagnosis was made using ante-mortem operating findings and surgical specimens in twenty-one cases. Though, thirty-one cases were estimated diagnosis based on post-mortem imaging or ante-mortem examinations, the exact original cause of death was not determined in 25 cases, and the cause of death could not be identified in eight cases without autopsy.Because in most cases the autopsy provides an exact cause of death, the necessity of autopsies should be more widely accepted in Japan.

This document builds upon recommendations from peer organizations and outlines a process for identifying maternal cases that should be reviewed. Severe maternal morbidity is associated with a high rate of preventability, similar to that of maternal mortality. It also can be considered a near miss for maternal mortality because without identification and treatment, in some cases, these conditions would lead to maternal death. Identifying severe morbidity is, therefore, important for preventing such injuries that lead to mortality and for highlighting opportunities to avoid repeat injuries. The two-step screen and review process described in this document is intended to efficiently detect severe maternal morbidity in women and to ensure that each case undergoes a review to determine whether there were opportunities for improvement in care. Like cases of maternal mortality, cases of severe maternal morbidity merit quality review. In the absence of consensus on a comprehensive list of conditions that represent severe maternal morbidity, institutions and systems should either adopt an existing screening criteria or create their own list of outcomes that merit review.

Unintended pregnancy remains a major public health problem in the United States. Access and cost issues are common reasons why women either do not use contraception or have gaps in use. A potential way to improve contraceptive access and use, and possibly decrease unintended pregnancy rates, is to allow over-the-counter access to oral contraceptives (OCs). Screening for cervical cancer or sexually transmitted infections is not medically required to provide hormonal contraception. Concerns include payment for pharmacist services, payment for over-the-counter OCs by insurers, and the possibility of pharmacists inappropriately refusing to provide OCs. Weighing the risks versus the benefits based on currently available data, OCs should be available over-the-counter. Women should self-screen for most contraindications to OCs using checklists.

Long-acting reversible contraception (LARC)—intrauterine devices and the contraceptive implant—are safe and appropriate contraceptive methods for most women and adolescents. The LARC methods are top-tier contraceptives based on effectiveness, with pregnancy rates of less than 1% per year for perfect use and typical use. These contraceptives have the highest rates of satisfaction and continuation of all reversible contraceptives. Adolescents are at high risk of unintended pregnancy and may benefit from increased access to LARC methods.

Preterm birth is the leading cause of neonatal mortality and the most common reason for antenatal hospitalization(1–4). In the United States, approximately 12% of all live births occur before term, and preterm labor preceded approximately 50% of these preterm births (5, 6). Although the causes of preterm labor are not well understood, the burden of preterm births is clear—preterm births account for approximately 70% of neonatal deaths and 36% of infant deaths as well as 25–50% of cases of long-term neurologic impairment in children (7–9). A 2006 report from the Institute of Medicine estimated the annual cost of preterm birth in the United States to be $26.2 billion or more than$51,000 per premature infant (10). However, identifying women who will give birth preterm is an inexact process.The purpose of this document is to present the various methods proposed to manage preterm labor and to review the evidence for the roles of these methods in clinical practice. Identification and management of risk factors for preterm labor are not addressed in this document.

The Maternal Death Exploratory Committee in Japan analyzed 313 maternal deaths that occurred in the country between January 1, 2010 and March 31, 2017. The details of the Committee have been described previously.1 The study was approved by the ethics board of the National Cerebral and Cardiovascular Center (Osaka, Japan) and the Japan Association of Obstetricians and Gynecologists. This investigation was conducted according to the principles expressed in the Declaration of Helsinki. Informed consent was not obtained from patients or their families, because the study was based on the analysis of institutional forms, and the patient records/information was anonymized. This article is protected by copyright. All rights reserved.

All women should be presumed to be eligible for participation in clinical studies. The potential for pregnancy should not automatically exclude a woman for participating in a clinical study, although the use of contraception may be required for participation. Research objectives should not interfere with appropriate clinical management. If a conflict arises between medically appropriate patient care and research objectives, patient care should prevail. Consent of the pregnant woman alone is sufficient for most research. Pregnant women considering participation in a research study should determine the extent to which the father is to be involved in the process of informed consent and the decision.

In this Committee Opinion, the American College of Obstetricians and Gynecologists Committee on Ethics presents various ethical considerations and arguments relevant to both prefertilization and postfertilization techniques for sex selection. The principal medical reason for sex selection is known or suspected risk of sex-linked genetic disorders. Other reasons sex selection is requested are personal, social, or cultural in nature. The Committee on Ethics supports the practice of offering patients procedures for the purpose of preventing serious sex-linked genetic diseases. However, the committee opposes meeting requests for sex selection for personal and family reasons, including family balancing, because of the concern that such requests may ultimately support sexist practices. Because a patient is entitled to obtain personal medical information, including information about the sex of her fetus, it will sometimes be impossible for health care professionals to avoid unwitting participation in sex selection.

In 2001, the American College of Obstetricians and Gynecologists and the American College of Medical Genetics introduced guidelines for prenatal and preconception carrier screening for cystic fibrosis. The American College of Obstetricians and Gynecologists has updated current guidelines for cystic fibrosis screening practices among obstetrician-gynecologists.

The reprocessing and reuse of single-use instruments has become increasingly common. Although there are limited data on reprocessed single-use devices, existing studies have found a significant rate of physical defects, performance issues, or improper decontamination. There are currently no data in the medical literature of studies evaluating the cost-effectiveness of reprocessed single-use devices in gynecologic surgery. The use of a reprocessed single-use device provides no direct benefit to an individual patient or her physician. It is the operating surgeon’s ethical responsibility to make a good faith effort to know whether reprocessed single-use devices are to be used, and to not use instruments if he or she has concerns about the quality or safety of the instrument(s). Studies on the safety, quality, and cost-effectiveness of reprocessed single-use devices in gynecologic surgery are needed. Physicians should be informed whether the instruments used in surgery are original or reprocessed, and adverse events should be reported to improve the safety information about reprocessed single-use devices.

Committee Opinions are intended to provide timely information on controversial issues, ethical concerns, and emerging approaches to clinical management. They represent the considered views of the sponsoring committee based on interpretation of published data in peer-reviewed journals. Committee Opinions are reviewed periodically for continued relevance or needed update. Note: Because individual Committee Opinions are withdrawn from and added to the series on a continuing basis, the titles listed in this index may not be identical to those contained in complete sets.

Adolescents make up an increasing percentage of the U.S. population with human immunodeficiency virus (HIV). Adolescent-focused care is critical to identify and reduce at-risk behavior, comorbidities, and partner transmission. Optimal medical and reproductive health care, both now and in the future, with an adolescent-focused approach, are important for HIV-infected adolescents. Adolescents who are infected with HIV should receive care that allows them to realize their sexual and reproductive goals while maximizing their personal health and minimizing the risk of unintended pregnancy, acquisition of new sexually transmitted infections, and transmission of infection to partners or offspring. Key strategies for preventing the spread of infection include, early diagnosis, guideline-based treatment, and partner notification of HIV status.

We examined the current status of human T-cell leukemia virus type 1 (HTLV-1) carrier in Japanese pregnant women, according to the results of HTLV-1 screening and confirmation tests of women who gave birth in Japan in 2011. We requested 2642 obstetrical facilities to provide information of HTLV-1 tests and 71.3% of them responded. Considering the response rate and the rate of implementation of confirmation tests, the number of HTLV-1 carrier in Japanese pregnant women was estimated to be 1620 (0.16%) per year.

The purpose of this Committee Opinion is to provide a review of recent studies regarding the potential relationship between induced abortion and subsequent breast cancer and to discuss methodologic challenges in this field of study. The American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice concludes that early studies of the relationship between prior induced abortion and breast cancer risk have been inconsistent and are difficult to interpret because of methodologic considerations. More rigorous recent studies argue against a causal relationship between induced abortion and a subsequent increase in breast cancer risk.

Antiphospholipid syndrome (APS) is an autoimmune disorder defined by the presence of characteristic clinical features and specified levels of circulating antiphospholipid antibodies (Box 1 and Box 2). Diagnosis requires that at least one clinical and one laboratory criterion are met. Because approximately 70% of individuals with APS are female (1), it is reasonably prevalent among women of reproductive age. Antiphospholipid antibodies are a diverse group of antibodies with specificity for binding to negatively charged phospholipids on cell surfaces. Despite the prevalence and clinical significance of APS, there is controversy about the indications for and types of antiphospholipid tests that should be performed in order to diagnose the condition. Much of the debate results from a lack of well-designed and controlled studies on the diagnosis and management of APS. The purpose of this document is to evaluate the data for diagnosis and treatment of APS.

An accurate and effective tracking or reminder system is useful for the modern practice of obstetrics and gynecology. Practices should not rely solely on the patient to complete all ordered studies and to follow up on health care provider recommendations. Health care providers should encourage their patients to complete studies believed essential for patient care within an acceptable time frame. Each office should establish a simple, reliable tracking and reminder system to facilitate communication, improve patient safety and quality of care, and minimize missed or delayed diagnoses.

Military service is associated with unique risks to women's reproductive health. As increasing numbers of women are serving in the military, and a greater proportion of United States Veterans are women, it is essential that obstetrician-gynecologists are aware of and well prepared to address the unique health care needs of this demographic group. Obstetrician-gynecologists should ask about women's military service, know the Veteran status of their patients, and be aware of high prevalence problems (eg, posttraumatic stress disorder, intimate partner violence, and military sexual trauma) that can threaten the health and well-being of these women. Additional research examining the effect of military and Veteran status on reproductive health is needed to guide the care for this population. Moreover, partnerships between academic departments of obstetrics and gynecology and local branches of the Veterans Health Administration are encouraged as a means of optimizing the provision of comprehensive health care to this unique group of women.

The nonmedical use of prescription drugs, particularly opioids, sedatives, and stimulants, has been cited as epidemic in the United States, accounting for increasing numbers of emergency department visits and deaths from reactions and overdoses. The prevalence of prescription drug abuse is similar among men and women. Those who abuse prescription drugs most often obtain them from friends and family either through sharing or theft. Physicians should screen all patients annually and early in prenatal care with a validated questionnaire for the nonmedical use of prescription drugs. They should provide preventive education for all patients and referral for treatment, when psychologic or physical drug dependence is identified. Physicians should also educate patients in the proper use, storage, and disposal of prescription drugs.

In the United States, most new cases of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) occur among women of color (primarily African American and Hispanic women). Most women of color acquire the disease from heterosexual contact, often from a partner who has undisclosed risk factors for HIV infection. Safe sex practices, especially consistent condom use, must be emphasized for all women, including women of color. A combination of testing, education, and brief behavioral interventions can help reduce the rate of HIV infection and its complications among women of color. In addition,biomedical interventions such as early treatment of patients infected with HIV and pre-exposure antiretroviral prophylaxis of high-risk individuals offer promise for future reductions in infections.