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Maternal-fetal therapy (MFT) is special because treatment of the fetus is exclusively possible through the body of another person, the pregnant woman. MFT is a broad specialty with diverse interventions. In this manuscript several examples of innovations in MFT are discussed to illustrate the shift of lifesaving interventions to interventions aiming to improve morbidity of the future child. The broadening of the scope and shift towards prenatal treatments improving morbidity result in new ethical challenges. Particularly attention is needed for counseling and (the risk of) therapeutic misconception.

Objective: To explore fetal medicine specialists' experiences of caring for parents following a diagnosis of fatal fetal anomaly (FFA) during the implementation of termination of pregnancy (TOP) for FFA for the first time., Design: Qualitative study., Setting: Fetal medicine units in the Republic of Ireland., Population: Ten fetal medicine specialists from five of the six fetal medicine units., Methods: nvivo 12 assisted in the thematic analysis of semi-structured in-depth face-to-face interviews., Main Outcome Measures: Fetal medicine specialists' experiences of prenatal diagnosis and holistic management of pregnancies complicated by FFA., Results: Four themes were identified: 'not fatal enough', 'interactions with colleagues', 'supporting pregnant women' and 'internal conflict and emotional challenges'. Fetal medicine specialists feared getting an FFA diagnosis incorrect because of media scrutiny and criminal liability associated with the TOP for FFA legislation. Challenges with the ambiguous and 'restrictive' legislation were identified that 'ostracised' severe anomalies. Teamwork was essential to facilitate opportunities for learning and peer support; however, conflict with colleagues was experienced regarding the diagnosis of FFA, the provision of feticide and palliative care to infants born alive following TOP for FFA. Participants reported challenges implementing TOP for FFA, including the absence of institutional support and 'stretched' resources. Fetal medicine specialists experienced internal conflict and a psychological burden providing TOP for FFA, but did so to 'provide full care for women'., Conclusions: Our study identified challenges regarding the suitability of the Irish legislation for TOP for FFA and its rapid introduction into clinical practice. It illustrates the importance of institutional and peer support, as well as the need for supportive management, in the provision of a new service., Tweetable Abstract: The implementation of termination services for fatal fetal anomaly is complex and requires institutional support., (© 2020 John Wiley & Sons Ltd.)

Lebanon has approximately one million Syrian refugees (SR) registered with the United Nations High Commission on Refugees (UNHCR) and an unknown number of unregistered SR, who cannot benefit from formal assistance. This study aimed to examine the livelihoods, coping strategies, and access to healthcare among SR based on registration status and accompanying formal assistance. A mixed-method approach with more emphasis on the qualitative design was adopted. A purposive convenient sampling approach was used to recruit SR from informal tented settlements (ITS) in the Beqaa region in Lebanon. Data collection included 19 focus group discussions (FGDs) that were conducted with participants, who were further divided into three groups: registered refugees with assistance, registered without assistance and unregistered. Twelve in-depth interviews were conducted with key informants from humanitarian organizations. All interviews and FGDs were audio recorded, transcribed, and thematically analyzed. SR were highly dependent on formal assistance when received, albeit being insufficient. Regardless of registration status, refugees resorted to informal livelihood strategies, including informal employment, child labor, early marriage, and accruing debt. Poor living conditions and food insecurity were reported among all SR. Limited healthcare access and high out-of-pocket costs led to limited use of antenatal care services, prioritizing life-threatening conditions, and resorting to alternative sources of healthcare. Severity of these conditions and their adverse health consequences were especially pronounced among unregistered refugees. Our findings shed light on the economic and health disparities among marginalized SR, with the lack of registration and formal assistance increasing their vulnerability. More tailored and sustainable humanitarian programs are needed to target the most vulnerable and hard-to-reach groups., Competing Interests: The authors have declared that no competing interests exist.

Despite wide diversity and scope, the ethical dimensions relevant to infections in pregnancy remain little explored. Important questions span topics with personal or wider societal and public health impact. The conceptualization of the status and responsibilities of the pregnant woman and the legitimate limits of third-party interests are key determinants of our appreciation of applicable ethical obligations., Competing Interests: Declaration of Competing Interest The author declare that he has no conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

If the worries about the coronavirus disease 2019 (COVID-19) pandemic are not already enough, some pregnant women have been questioning whether the hospital is a safe or safe enough place to deliver their babies and therefore whether they should deliver out-of-hospital during the pandemic. In the United States, planned out-of-hospital births are associated with significantly increased risks of neonatal morbidity and death. In addition, there are obstetric emergencies during out-of-hospital births that can lead to adverse outcomes, partly because of the delay in transporting the woman to the hospital. In other countries with well-integrated obstetric services and well-trained midwives, the differences in outcomes of planned hospital birth and planned home birth are smaller. Women are empowered to make informed decisions when the obstetrician makes ethically justified recommendations, which is known as directive counseling. Recommendations are ethically justified when the outcomes of one form of management is clinically superior to another. The outcomes of morbidity and mortality and of infection control and prevention of planned hospital birth are clinically superior to those of out-of-hospital birth. The obstetrician therefore should recommend planned hospital birth and recommend against planned out-of-hospital birth during the COVID-19 pandemic. The COVID-19 pandemic has increased stress levels for all patients and even more so for pregnant patients and their families. The response in this difficult time should be to mitigate this stress and empower women to make informed decisions by routinely providing counseling that is evidence-based and directive.

A 28-year-old woman suffered a traffic accident resulting in severe head injuries with deleterious prognosis. Diagnostics further revealed a hitherto unknown pregnancy, at suspected week 9. Based on the patient's wish to donate organs, brain death protocol confirmed irreversible loss of brain function. Yet, vital pregnancy rendered organ transplantation impossible. Multiple ethical and legal issues arose, from invalidation of established legal care after brain death to the delivery of a healthy child after trauma and long-term critical care. After medicolegal and ethical counselling, pregnancy was sustained, and the goal of organ donation postponed. Critical care focused on foetal homeostasis. At 30+4 weeks, a viable girl was born via assisted vaginal delivery. Postpartal organ donation resulted in heart, kidney and pancreas transplantation. The case emphasises the medical, legal and ethical challenges to combine two apparently diametrical goals: the successful full-term pregnancy and the fulfilment of a patient's wish to donate organs., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

This paper examines the practice implications of various state policies that provide publicly funded prenatal care to undocumented immigrants for health care workers who see undocumented patients. Data were collected through in-depth interviews with purposively sampled health care workers at safety net clinics in California, Maryland, Nebraska, and New York. Health care workers were asked about the process through which undocumented patients receive prenatal care in their health center and the ethical tensions and frustrations they encounter when providing or facilitating this care under policy restrictions. Respondents discussed several professional practice norms as well as the ethical tensions they encountered when policy or institutional constraints prevented them from living up to professional norms. Using Nancy Berlinger's "workarounds" framework, this paper examines health care workers' responses to the misalignment of their professional norms and the policy restrictions in their state. These findings suggest that the prenatal policies in each state raise ethical and professional challenges for the health care workers who implement them.

Objective: Some prenatal situations may be characterized as concerning on the medico-psycho-social level, leaving a risk of danger to the unborn child, raising different issues between prevention and protection, legal and justified. The objectives were to evaluate the professionals’ perceptions with respect to the most worrying prenatal situations, to assess the practices of care, and to identify potential measures for improvement., Method: The research was based on a qualitative-quantitative methodology: Semi-directed interviews with experts who allowed the construction of a questionnaire, validated according to a Delphi-type methodology, and a regional survey based on the questionnaire, which was directed to the maternities and the departmental councils., Results: The participation rate was 69%. The survey revealed a willingness to create regional perinatal partnerships, an awareness of ethical issues (information sharing, conflict of values, ethics of Care, vulnerability…), and a lack of knowledge of the regulatory framework (legal, ethical). Different possibilities of improvement have been proposed., Conclusion: Simultaneously, this study participates in the observatory missions of the ethical committee, as well as in public policies of perinatal prevention.

Obesity is a medical condition that may be associated with bias among health care professionals, and this bias may result in disrespectful or inadequate care of patients with obesity. Obstetrician-gynecologists regularly care for patients with obesity and play an integral role in advocating for best practices in health care and optimizing health outcomes for patients with obesity. Obstetrician-gynecologists should be prepared to care for their patients with obesity in a nonjudgmental manner, being cognizant of the medical and societal implications of obesity. This Committee Opinion has been updated from its previous version to focus on obesity bias within the medical community and to provide practical guidance using people-first language instead of labels (ie, "patients with obesity" versus "obese patients") to help obstetrician-gynecologists deliver effective, compassionate medical care that meets the needs of patients with obesity.

Obesity is a medical condition that may be associated with bias among health care professionals, and this bias may result in disrespectful or inadequate care of patients with obesity. Obstetrician-gynecologists regularly care for patients with obesity and play an integral role in advocating for best practices in health care and optimizing health outcomes for patients with obesity. Obstetrician-gynecologists should be prepared to care for their patients with obesity in a nonjudgmental manner, being cognizant of the medical and societal implications of obesity. This Committee Opinion has been updated from its previous version to focus on obesity bias within the medical community and to provide practical guidance using people-first language instead of labels (ie, "patients with obesity" versus "obese patients") to help obstetrician-gynecologists deliver effective, compassionate medical care that meets the needs of patients with obesity.

The Pre-Conception and Pre-Natal Diagnostic Techniques Act was written to prevent societally unacceptable harms including intentional sex selection. The pragmatism required to enforce this law has profound effects on the ability of rural Indians to access diagnostic ultrasonography. In so doing, it may have inadvertently placed a heavier burden on the poorest and worsened health inequity in India, creating serious ethical and justice concerns. It is time to re-examine and update the law such that diagnostic ultrasonography is widely available in even the most peripheral primary health and community health centres. Shorter, more accessible ultrasonography training courses should be offered; collaboration between radiologists and rural practitioners and facilities should be encouraged. Finally, modern ultrasound machines can carefully record all images via a "silent observer" modality. With some modifications to previously used silent observer modalities, this technology allows both greater access and better policing of potential misuse of ultrasound technology.

Nearly 7% of US citizens born each year have at least one undocumented parent, but many pregnant undocumented immigrants are ineligible for public insurance covering prenatal care due to their immigration status. This article reviews national-level and state-level policies affecting access to prenatal care for members of this population. This article also considers ethical challenges posed by some policies that create obstacles to patients' accessing health care that is universally recommended by professional guidelines., (© 2019 American Medical Association. All Rights Reserved.)

Perinatology is a dynamically developing field of medicine. The progress of technology in recent decades has made it possible to recognize birth defects very early, including those which are lethal or genetically determined. In many clinical situations, it is no longer possible to work alone to reach a definitive diagnosis, plan treatment or predict the clinical course of the affected fetus/newborn. There is a need for teamwork, which ensures the proper, early care starting in the fetal period, not only in the delivery room or NICU. This paper discusses the ethical foundations of creating interdisciplinary teams, taking as an example the Interdisciplinary Team for Fetal Malformation at the Institute of Mother and Child in Warsaw, which has been active for 25 years, and presents how it works in practice. On the basis of the clinical cases that are examined, practical guidelines were formulated for both the work of medical teams and the way parents are informed about the clinical situation of their child and about sharing the care after the birth of the child. A document was also proposed with information on prenatal diagnosis, decisions made by the interdisciplinary team regarding the mother and child, as well as the conclusions resulting from discussions with parents.

Background: Mother-to-child transmission (MTCT) of the Human Immunodeficiency -Virus (HIV) is a serious public health problem, contributing up to 90% of childhood HIV infections. In Tanzania, the prevention-of-mother-to-child-transmission (PMTCT) feature of the HIV programme was rolled out in 2000. The components of PMTCT include counselling and HIV testing directed at antenatal clinic attendees. It is through the process of Provider Initiated Counseling and Testing (PITC) that counselling is offered participant confidentiality and voluntariness are upheld and valid consent obtained. The objective of the study was to explore antenatal clinic attendees' experiences of the concept of voluntariness vis- a- vis the implementation of prior counseling and subsequent testing for HIV under the PITC as part of their antenatal care., Methods: In-depth interviews were conducted with17 antenatal clinic attendees and 6 nursing officers working at the Muhimbili National Hospital (MNH) antenatal clinic. The study data were analyzed using qualitative content analysis., Results: Antenatal clinic attendees' accounts suggested that counselling and testing for HIV during pregnancy was voluntary, and that knowledge of their HIV status led them to access appropriate treatment for both mother and her newborn baby. They reported feeling no pressure from nursing officers, and gave verbal consent to undergo the HIV test. However, some antenatal clinic attendees reported pressure from their partners to test for HIV. Healthcare providers were thus faced with a dilemma of disclosure/ nondisclosure when dealing with discordant couples., Conclusion: Antenatal clinic attendees at MNH undertook the PITC for HIV voluntarily. This was enhanced by their prior knowledge of HIV, the need to prevent mother- to- child transmission of HIV, and the effectiveness of the voluntary policy implemented by nursing officers.

The United States, along with other resource-rich countries, leads global health care by advancing medical care through randomized controlled trials (RCTs). While most medical research is conducted in these resource-rich areas, RCTs, including replications of previous trials, are additionally carried out in low- and middle-income countries. On the basis of positive findings from several RCTs conducted in high-income countries, the Antenatal Corticosteroids Trial (ACT) evaluated the effectiveness of antenatal corticosteroids in reducing neonatal mortality in low- and middle-income countries. ACT, however, was undertaken in dramatically different health care infrastructures and did not confirm the results of previous studies. We argue that it is neither clinically appropriate nor ethically acceptable to extrapolate findings from one region to another without accounting for the disparate cultural values, goals of care, and health services infrastructure that impact clinical outcomes., (© 2018 American Medical Association. All Rights Reserved.)

Despite advances in life-saving technology for critically ill neonates, challenges continue to arise for infants delivered with extreme prematurity, congenital anomalies, and genetic conditions that exceed the limits of currently available interventions. In these situations, parents are forced to make cognitively and emotionally difficult decisions, in discussion with a neonatologist, regarding how aggressively to provide supportive measures at the time of delivery and at what point burdens of therapy outweigh benefits. Current guidelines recommend that parents' values should guide these decisions; however, little is known about the values parents hold, and how those values are employed in the context of complexity, uncertainty, and emotionality of these situations. Systematic investigation of how parents derive their values and how clinicians should engage with parents about those values is necessary to guide the development of interventions to enhance shared decision-making processes, ultimately improving satisfaction, coping, and resilience and minimizing the potential for regret., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Twin gestations are increasing in prevalence worldwide, and are potentially subject to medical complications which present uniquely complex ethical and psychosocial challenges for the pregnant patient and obstetrician to navigate. In this article, we explore these issues as they relate to medical decision-making in cases of discordant growth and discordant anomalies in both monochorionic and dichorionic twin pregnancies, including those affected by twin-twin transfusion syndrome, with particular attention to scenarios in which the individual fetuses hold competing interests. For each of these scenarios, we consider how decisions may positively or negatively impact one or both fetuses, and how familiarity with population outcomes, as well as sensitivity to the complex psychosocial circumstances surrounding these pregnancies, can support and inform shared decision-making., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Spina bifida and congenital talipes equinovarus (CTEV) are common congenital malformations which may occur together and increase morbidity. Monozygous twins are particularly at risk of these malformations and discordance in one type of malformation is typical. The occurrence of both spina bifida and CTEV in one twin of a monozygotic pair is rare., Case Presentation: A 22 year-old Cameroonian primigravida at 36 weeks of a twin gestation was received in our district hospital at the expulsive phase of labour on a background of sub-optimal antenatal care. A caesarean section indicated for cephalo-pelvic disproportion was performed and life monoamniotic male twins were extracted. The first twin was normal. The second twin had spina bifida cystica and severe bilateral CTEV. Routine postnatal care was ensured and at day 2 of life, the affected twin was evacuated to a tertiary hospital for proper management. He was later on reported dead from complications of hydrocephalus., Conclusions: Spina bifida cystica with severe bilateral CTEV in one twin of a monoamniotic pair illustrates the complexity in the interplay of causal factors of these malformations even among monozygotic twins who are assumed to share similar genetic and environmental features. The occurrence and poor outcome of the malformations was probably potentiated by poor antenatal care. With postnatal diagnoses, a better outcome was difficult to secure even with prompt referral. Early prenatal diagnoses and appropriate counseling of parents are cardinal.

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].

In 2013, physician-researchers announced that a baby in Mississippi had been 'functionally cured' of HIV [Persaud, D., Gay, H., Ziemniak, C. F., Chen, Y. H., Piatak, M., Chun, T.-W., … Luzuriaga, K. (2013b, March). Functional HIV cure after very early ART of an infected infant. Paper presented at the 20th conference on retroviruses and opportunistic infections, Atlanta, GA]. Though the child later developed a detectable viral load, the case remains unprecedented, and trials to build on the findings are planned [National Institute of Allergy and Infectious Diseases. (2014). 'Mississippi baby' now has detectable HIV, researchers find. Retrieved from http://www.niaid.nih.gov/news/newsreleases/2014/pages/mississippibabyhiv.aspx ]. Whether addressing HIV 'cure' or 'remission', scrutiny of this case has focused largely on scientific questions, with only introductory attention to ethics. The social inequalities and gaps in care that made the discovery possible - and their ethical implications for paediatric HIV remission - have gone largely unexamined. This paper describes structural inequalities surrounding the 'Mississippi baby' case and a parallel case in South Africa, where proof-of-concept studies are in the early stages. We argue that an ethical programme of research into infant HIV remission ought to be 'structurally competent', and recommend that paediatric remission studies consider including a research component focused on social protection and barriers to care.

Policy statements regarding antenatal consultations for preterm labour are guided by physicians' concerns for upholding the legal doctrine of informed consent, through the provision of standardised homogeneous medical information. This approach, led by classical in-control conceptions of patient autonomy, conceives moral agents as rational, independent, self-sufficient decision-makers. Recent studies on these antenatal consultations have explored patients' perspectives, and these differ from guidelines' suggestions. Relational autonomy - which understands moral agents as rational, emotional, creative and interdependent - resonates impressively with these new data., Conclusion: A model for antenatal consultations is proposed. This approach encourages clinicians to explore individual patients' lived experiences and engage in trusting empowering relationships. Moreover, it calls on physicians to enhance patients' relational autonomy by becoming advocates for their patients within healthcare institutions and professional organisations, while calling for broadscale policy changes to encourage further funding and support in investigations of the patient's voice., (©2016 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Indigenous women in Mesoamerica experience disproportionately high maternal mortality rates and are less likely to have institutional deliveries. Identifying correlates of institutional delivery, and satisfaction with institutional deliveries, may help improve facility utilization and health outcomes in this population. We used baseline surveys from the Salud Mesoamérica Initiative to analyze data from 10,895 indigenous and non-indigenous women in Guatemala and Mexico (Chiapas State) and indigenous women in Panama. We created multivariable Poisson regression models for indigenous (Guatemala, Mexico, Panama) and non-indigenous (Guatemala, Mexico) women to identify correlates of institutional delivery and satisfaction. Compared to their non-indigenous peers, indigenous women were substantially less likely to have an institutional delivery (15.2% vs. 41.5% in Guatemala (P<0.001), 29.1% vs. 73.9% in Mexico (P<0.001), and 70.3% among indigenous Panamanian women). Indigenous women who had at least one antenatal care visit were more than 90% more likely to have an institutional delivery (adjusted risk ratio (aRR) = 1.94, 95% confidence interval (CI): 1.44-2.61), compared to those who had no visits. Indigenous women who were advised to give birth in a health facility (aRR = 1.46, 95% CI: 1.18-1.81), primiparous (aRR = 1.44, 95% CI: 1.24-1.68), informed that she should have a Caesarean section (aRR = 1.41, 95% CI: 1.21-1.63), and had a secondary or higher level of education (aRR = 1.36, 95% CI: 1.04-1.79) also had substantially higher likelihoods of institutional delivery. Satisfaction among indigenous women was associated with being able to be accompanied by a community health worker (aRR = 1.15, 95% CI: 1.05-1.26) and facility staff speaking an indigenous language (aRR = 1.10, 95% CI: 1.02-1.19). Additional effort should be exerted to increase utilization of birthing facilities by indigenous and poor women in the region. Improving access to antenatal care and opportunities for higher-level education may increase institutional delivery rates, and providing culturally adapted services may improve satisfaction.

Drawing on sociological and anthropological studies, the aim of this article is to reconstruct how obstetric technologies contribute to a moral conception of pregnancy and motherhood, and to evaluate that conception from a normative point of view. Obstetrics and midwifery, so the assumption, are value-laden, value-producing and value-reproducing practices, values that shape the social perception of what it means to be a "good" pregnant woman and to be a "good" (future) mother. Activities in the medical field of reproduction contribute to "kinning", that is the making of particular social relationships marked by closeness and special moral obligations. Three technologies, which belong to standard procedures in prenatal care in postmodern societies, are presently investigated: (1) informed consent in prenatal care, (2) obstetric sonogram, and (3) birth plan. Their widespread application is supposed to serve the moral (and legal) goal of effecting patient autonomy (and patient right). A reconstruction of the actual moral implications of these technologies, however, reveals that this goal is missed in multiple ways. Informed consent situations are marked by involuntariness and blindness to social dimensions of decision-making; obstetric sonograms construct moral subjectivity and agency in a way that attribute inconsistent and unreasonable moral responsibilities to the pregnant woman; and birth plans obscure the need for a healthcare environment that reflects a shared-decision-making model, rather than a rational-choice-framework.

Background: Obstetric ultrasound has become a significant tool in obstetric practice, however, it has been argued that its increasing use may have adverse implications for women's reproductive freedom. This study aimed to explore Australian obstetricians' experiences and views of the use of obstetric ultrasound both in relation to clinical management of complicated pregnancy, and in situations where maternal and fetal health interests conflict., Methods: A qualitative study was undertaken as part of the CROss-Country Ultrasound Study (CROCUS). Interviews were held in November 2012 with 14 obstetricians working in obstetric care in Victoria, Australia. Data were analysed using qualitative content analysis., Results: One overall theme emerged from the analyses: The ethical challenge of balancing maternal and fetal health interests, built on four categories: First, Encountering maternal altruism' described how pregnant women's often 'altruistic' position in relation to the health and wellbeing of the fetus could create ethical challenges in obstetric management, particularly with an increasing imbalance between fetal benefits and maternal harms. Second, 'Facing shifting attitudes due to visualisation and medico-technical advances' illuminated views that ultrasound and other advances in care have contributed to a shift in what weight to give maternal versus fetal welfare, with increasing attention directed to the fetus. Third, 'Guiding expectant parents in decision-making' described the difficult task of facilitating informed decision-making in situations where maternal and fetal health interests were not aligned, or in situations characterised by uncertainty. Fourth, 'Separating private from professional views' illuminated divergent views on when the fetus can be regarded as a person. The narratives indicated that the fetus acquired more consideration in decision-making the further the gestation progressed. However, there was universal agreement that obstetricians could never act on fetal grounds without the pregnant woman's consent., Conclusions: This study suggests that medico-technical advances such as ultrasound have set the scene for increasing ethical dilemmas in obstetric practice. The obstetricians interviewed had experienced a shift in previously accepted views about what weight to give maternal versus fetal welfare. As fetal diagnostics and treatment continue to advance, how best to protect pregnant women's right to autonomy requires careful consideration and further investigation.

Objective: Prenatal counseling at the threshold of viability is a challenging yet critically important activity, and care guidelines differ across cultures. Studying how this task is performed in the actual clinical environment is extremely difficult. In this pilot study, we used simulation as a methodology with 2 aims as follows: first, to explore the use of simulation incorporating a standardized pregnant patient as an investigative methodology and, second, to determine similarities and differences in content and style of prenatal counseling between American and Dutch neonatologists., Methods: We compared counseling practice between 11 American and 11 Dutch neonatologists, using a simulation-based investigative methodology. All subjects performed prenatal counseling with a simulated pregnant patient carrying a fetus at the limits of viability. The following elements of scenario design were standardized across all scenarios: layout of the physical environment, details of the maternal and fetal histories, questions and responses of the standardized pregnant patient, and the time allowed for consultation., Results: American subjects typically presented several treatment options without bias, whereas Dutch subjects were more likely to explicitly advise a specific course of treatment (emphasis on partial life support). American subjects offered comfort care more frequently than the Dutch subjects and also discussed options for maximal life support more often than their Dutch colleagues., Conclusions: Simulation is a useful research methodology for studying activities difficult to assess in the actual clinical environment such as prenatal counseling at the limits of viability. Dutch subjects were more directive in their approach than their American counterparts, offering fewer options for care and advocating for less invasive interventions. American subjects were more likely to offer a wider range of therapeutic options without providing a recommendation for any specific option.

Background: In India, approximately 49,000 women living with HIV become pregnant and deliver each year. While the government of India has made progress increasing the availability of prevention of mother-to-child transmission of HIV (PMTCT) services, only about one quarter of pregnant women received an HIV test in 2010, and about one-in-five that were found positive for HIV received interventions to prevent vertical transmission of HIV., Methods: Between February 2012 to March 2013, 14 HIV-positive women who had recently delivered a baby were recruited from HIV positive women support groups, Government of India Integrated Counseling and Testing Centers, and nongovernmental organizations in Mysore and Pune, India. In-depth interviews were conducted to examine their general experiences with antenatal healthcare; specific experiences around HIV counseling and testing; and perceptions about their care and follow-up treatment. Data were analyzed thematically using the human rights framework for HIV testing adopted by the United Nations and India's National AIDS Control Organization., Results: While all of the HIV-positive women in the study received HIV and PMTCT services at a government hospital or antiretroviral therapy center, almost all reported attending a private clinic or hospital at some point in their pregnancy. According to the participants, HIV testing often occurred without consent; there was little privacy; breaches of confidentiality were commonplace; and denial of medical treatment occurred routinely. Among women living with HIV in this study, violations of their human rights occurred more commonly in private rather than public healthcare settings., Conclusions: There is an urgent need for capacity building among private healthcare providers to improve standards of practice with regard to informed consent process, HIV testing, patient confidentiality, treatment, and referral of pregnant women living with HIV.

Critical advances in prevention of mother-to-child-transmission (MTCT) of the HIV in the perinatal period have changed practice recommendations for HIV screening for pregnant women. Using case studies we illustrate the ethical complexities and implications of opt-out HIV testing for pregnant women. Despite the potential for compromised informed consent, an opt-out HIV screening approach is ethically defensible., (© 2013 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

In the UK, putative fathers are encouraged to be involved in antenatal and maternal health care, in the belief that involving men as early as possible lays the foundation for better, more involved fatherhood. Integrating men into maternity care can, however, have hitherto unexplored ethical complexities. We begin by providing three ethical justifications for involving men in antenatal and maternity health care, and then discuss how each necessarily constrains the nature of this involvement. The medical setting itself creates some of the difficulties. This observation leads us into a broader exploration of the medicalisation of men's transition to fatherhood., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The still experimental nature of prenatal gene therapy carries a certain degree of risk, both for the pregnant mother as well as for the fetus. Some of the risks are procedural hazards already known from more conventional fetal medicine interventions. Others are more specific to gene therapy such as the potential for interference with normal fetal development, the possibility of inadvertent germ line gene transfer, and the danger of oncogenesis. This chapter reviews the potential risks in relation to the expected benefits of prenatal gene therapy. It discusses the scientific, ethical, legal, and social implications of this novel preventive approach to genetic disease and outlines preconditions to be met in preparation for a potential future clinical application.

Recent global advances in available technology to prevent mother-to-child HIV transmission necessitate a rethinking of contemporary and previous ethical debates on HIV testing as a means to preventing vertical transmission. In this paper, we will provide an ethical analysis of HIV-testing strategies of pregnant women. First, we argue that provider-initiated opt-out HIV testing seems to be the most effective HIV test strategy. The flip-side of an opt-out strategy is that it may end up as involuntary testing in a clinical setting. We analyse this ethical puzzle from a novel perspective, taking into account the moral importance of certain hypothetical preferences of the child, as well as the moral importance of certain actual preferences of the mother. Finally, we balance the conflicting concerns and try to arrive at an ethically sound solution to this dilemma. Our aim is to introduce a novel perspective from which to analyse testing strategies, and to explore the implications and possible benefits of our proposal. The conclusion from our analysis is that policies that recommend provider-initiated opt-out HIV testing of pregnant mothers, with a risk of becoming involuntary testing in a clinical setting, are acceptable. The rationale behind this is that the increased availability of very effective and inexpensive life-saving drugs makes the ethical problems raised by the possible intrusiveness of HIV testing less important than the child's hypothetical preferences to be born healthy. Health care providers, therefore, have a duty to offer both opt-out HIV testing and available PMTCT (preventing mother-to-child transmission) interventions., (© 2011 Blackwell Publishing Ltd.)

This paper describes the experience of 'Pamela*, mother of a child with spina bifida, diagnosed prenatally. It was disclosed during a research project exploring 'Family Centred Care' (FCC) with disabled children, and a very challenging ethical dilemma arose. This mother felt unsupported in her decision to go ahead with having her baby with spina bifida; this was in contrast to the support she received for her disabled child, once born. The discussion will focus around the challenge of supporting parents in decision making in midwifery and health care practice.

Alcohol use during pregnancy may have severe and lasting effects on the developing fetus. Unfortunately it is often difficult to detect and address maternal drinking, as previous articles in this series have demonstrated. The difficulty is only compounded by a number of ethical quandaries and legal concerns. Underlying most of these concerns is a particularly agonizing conflict of obligations: to protect vulnerable, nascent human life on the one hand, and to preserve the privacy, dignity, and trust of one's patient on the other.

Decision-making for extremely immature preterm infants at the margins of viability is ethically, professionally, and emotionally complicated. A standard for prenatal consultation should be developed incorporating assessment of parental decision-making preferences and styles, a communication process involving a reciprocal exchange of information, and effective strategies for decisional deliberation, guided by and consistent with parental moral framework. Professional caregivers providing perinatal consultations or end-of-life counseling for extremely preterm infants should be sensitive to these issues and be taught flexibility in counseling techniques adhering to consistent guidelines. Emphasis must shift away from physician beliefs and behaviors about the boundaries of viability., (Copyright © 2011 Elsevier Inc. All rights reserved.)

As the HIV epidemic continues to grow worldwide, women are increasingly and disproportionally affected. With the introduction of anti-retroviral medications that have been found to effectively prevent perinatal transmission of HIV, the approach to HIV testing in pregnant women has grown increasingly more controversial. In recent years, the model of voluntary counseling and testing (VCT) has come into question with opt-out testing now advocated for by the Centers for Disease Control and occurring widely in pregnancy. The benefits of opt-out testing are numerous and may justify its use in replacing the VCT that many have come to see as insufficient. An ethical analysis of opt-out testing suggests it may be at odds with true informed consent and involve a degree of coercion that would not be allowed outside the prenatal setting. If opt-out testing is going to remain the standard of care then the ethical issues it raises must be made transparent. Strategies need to be designed for ensuring that HIV counseling and testing in pregnancy is done in accordance with ethical and reproductive rights principles.

Appeals to the moral authority of nature play an important role in ethical discussions about the acceptability of prenatal testing. While opponents consider testing a dangerous violation of the moral inviolable course of nature, defenders see testing as a new step in improving dominion over nature. In this study we explored the meaning of appeals to nature among pregnant women to whom a prenatal screening test was offered and the impact of these appeals on their choices regarding the acceptance of screening. Contrary to theoretical debates we found that appeals to the moral authority of nature do not prevent women from welcoming the possibilities of controlling the outcomes of pregnancy, neither do they provide prima facie justification for (not) intervening in the natural course of events. Both acceptors and decliners believed in an inherent morality in nature that must be respected. They welcome the possibility of knowing more about the health of the fetus and to make their own reproductive decisions. Concerns for the quality of their child's life and for their capacity to assure a good life for their family and disabled child appear to play a central role in the decision regarding the use of screening. Appeals to nature can be interpreted as an attempt to justify beliefs regarding suffering that must be avoided and the impact that family interests may have on the decision. These findings have significant implications for ethical guidance in debates about the acceptability and boundaries of control of offspring characteristics by prenatal testing.

Empirical evidence suggests that some health professionals believe consent procedures for the emerging technology of non-invasive prenatal diagnosis (NIPD) should become less rigorous than those currently used for invasive prenatal testing. In this paper, we consider the importance of informed consent and informed choice procedures for protecting autonomy in those prenatal tests which will give rise to a definitive result. We consider whether there is anything special about NIPD that could sanction a change to consent procedures for prenatal diagnosis or otherwise render informed decision-making less important. We accept the claim that the absence of risk of miscarriage to some extent lessens the gravity of the decision to test compared with invasive methods of testing. However, we also claim that the definitive nature of the information received, and the fact that the information can lead to decisions of great significance, makes NIPD an important choice. This choice should only be made by means of a rigorous and appropriately supported decision-making process (assuming that this is what the pregnant woman wants). We conclude that, on balance, consent procedures for NIPD should mirror those for invasive testing, albeit without the need to emphasise procedure-related risk.

Purpose: The purpose of this study was to describe provider characteristics African American pregnant women identified as important when interacting with their prenatal care providers in an outpatient office setting., Study Design: A descriptive qualitative design was used to explore provider characteristics desired by African American women receiving prenatal care at two inner-city hospital-based obstetric clinics. A total of 22 African American women between the ages of 19 and 28 years participated in the study., Findings: Four major provider characteristic themes emerged from the data: (a) demonstrating quality patient-provider communication, (b) providing continuity of care, (c) treating the women with respect, and (d) delivering compassionate care., Discussion: An overarching theme revealed by the data analysis was the desire by African American women in this study to have their prenatal providers know and remember them. They wanted their providers to understand the context of their lives from their prenatal interactions. Incorporating findings from this study to improve patient-provider interactions during prenatal care could provide an increased understanding of the many complex variables affecting African American women's lives., Implications: Prenatal care provides an opportunity for African American women to develop a trusting relationship with a provider. Developing models of prenatal care congruent with the realities of African American women's lives has the potential to improve patient- provider interactions and potentially affect birth outcomes.