With the growing concerns of Coronavirus Disease 2019 (COVID-19), we wanted to share valuable resources for prevention, especially during your fertility and/or pregnancy care. The prevention of COVID-19 is of utmost priority to DIRM, as we are taking all preventative measures with both our staff and patients.
Only our Newark office will be open Monday and Friday mornings, until further notice.
The icon to the left will take you directly to the CDC’s COVID-19 website for all the latest details.
We are constantly monitoring the daily developments related to the spread and risks of novel coronavirus (COVID-19). Our priority at DIRM always remains the health and safety of our patients as well as our staff. To comply with guidance from CDC, WHO, and local public health authorities we are implementing and enhancing our screening policies and precautions for all patients who enter our office.
Tuesday afternoon, The American Society for Reproductive Medicine (ASRM) official statement included above released the following guidelines and recommendations:
This includes but is not limited to:
- Suspend initiation of new treatment cycles, including ovulation induction, intrauterine inseminations (IUIs), in vitro fertilization (IVF) including retrievals and frozen embryo transfers, as well as non-urgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers whether fresh or frozen.
- Continue to care for patients who are currently “in-cycle” or who require urgent stimulation and cryopreservation.
- Suspend elective surgeries and non-urgent diagnostic procedures.
- Minimize in-person interactions and increase utilization of telehealth.
Patients who are in the midst of their treatment may continue their current cycle. Our care team will counsel patients who wish to continue this cycle about the risks of achieving a pregnancy at this time.
DIRM will continue to do Telemedicine consults, monitor diagnostic cycles, perform diagnostic procedures in the office and monitor patients who are pregnant. Our decision was made by our clinical team based on the above recommendations from The American Society for Reproductive Medicine (ASRM). ASRM will reevaluate these recommendations on March 30, 2020.
Each patient will be contacted directly to discuss rescheduling options. We greatly appreciate your patience as we attempt to accommodate everyone’s schedule.
We understand that this is disappointing news for our patients, and we are committed to resuming care as soon as safely possible.
We will continue to update patients as changes in the COVID-19 pandemic evolve.
Please call our office immediately if:
- You develop symptoms, and have been in close contact with a person known to have COVID-19
- Shortness of Breath
- Have recently traveled from an area with widespread or ongoing community spread of COVID-19.
- We will accommodate patients who are identified as a potential risk with telemedicine consultation
There is currently no vaccine to prevent coronavirus disease 2019 (COVID-19).
The best way to prevent illness is to avoid being exposed to this virus.
The virus is thought to spread mainly from person-to-person.
- Between people who are in close contact with one another (within about 6 feet).
- Through respiratory droplets produced when an infected person coughs or sneezes.
These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.
Take steps to protect yourself
Clean your hands often
- Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
- If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry.
- Avoid touching your eyes, nose, and mouth with unwashed hands.
- Avoid close contact with people who are sick
- Put distance between yourself and other people if COVID-19 is spreading in your community. This is especially important for people who are at higher risk of getting very sick.
Take steps to protect others
Stay home if you’re sick
- Cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow.
- Throw used tissues in the trash.
- Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not readily available, clean your hands with a hand sanitizer that contains at least 60% alcohol.
- If you are sick: You should wear a facemask when you are around other people (e.g., sharing a room or vehicle) and before you enter a healthcare provider’s office. If you are not able to wear a facemask (for example, because it causes trouble breathing), then you should do your best to cover your coughs and sneezes, and people who are caring for you should wear a facemask if they enter your room. Learn what to do if you are sick.
- If you are NOT sick: You do not need to wear a facemask unless you are caring for someone who is sick (and they are not able to wear a facemask). Facemasks may be in short supply and they should be saved for caregivers.
- Clean AND disinfect frequently touched surfaces daily. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.
- If surfaces are dirty, clean them: Use detergent or soap and water prior to disinfection.
- Stay home: People who are mildly ill with COVID-19 are able to isolate at home during their illness. You should restrict activities outside your home, except for getting medical care.
- Avoid public areas:Do not go to work, school, or public areas.
- Avoid public transportation: Avoid using public transportation, ride-sharing, or taxis.
- Stay away from others: As much as possible, you should stay in a specific room and away from other people in your home. Also, you should use a separate bathroom, if available.
- Limit contact with pets & animals: You should restrict contact with pets and other animals while you are sick with COVID-19, just like you would around other people. Although there have not been reports of pets or other animals becoming sick with COVID-19, it is still recommended that people sick with COVID-19 limit contact with animals until more information is known about the virus.
- Cover: Cover your mouth and nose with a tissue when you cough or sneeze.
- Dispose: Throw used tissues in a lined trash can.
- Wash hands: Immediately wash your hands with soap and water for at least 20 seconds or, if soap and water are not available, clean your hands with an alcohol-based hand sanitizer that contains at least 60% alcohol.Wear a facemask if you are sick
- If you are sick: You should wear a facemask when you are around other people (e.g., sharing a room or vehicle) or pets and before you enter a healthcare provider’s office.
- If you are caring for others: If the person who is sick is not able to wear a facemask (for example, because it causes trouble breathing), then people who live with the person who is sick should not stay in the same room with them, or they should wear a facemask if they enter a room with the person who is sick.Call ahead before visiting your doctor
- Call ahead: If you have a medical appointment, call the healthcare provider and tell them that you have or may have COVID-19. This will help the healthcare provider’s office take steps to keep other people from getting infected or exposed.When possible, have another member of your household care for your animals while you are sick. If you are sick with COVID-19, avoid contact with your pet, including petting, snuggling, being kissed or licked, and sharing food. If you must care for your pet or be around animals while you are sick, wash your hands before and after you interact with pets and wear a facemask. See COVID-19 and Animals for more information.
- Wash hands: Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food.
- Hand sanitizer: If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry.
- Soap and water: Soap and water are the best option if hands are visibly dirty.
- Avoid touching: Avoid touching your eyes, nose, and mouth with unwashed hands.
- Do not share: You should not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home.
- Wash thoroughly after use: After using these items, they should be washed thoroughly with soap and water.
- Clean and disinfect: Practice routine cleaning of high touch surfaces.
High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables.
- Disinfect areas with bodily fluids: Also, clean any surfaces that may have blood, stool, or body fluids on them.
- Household cleaners: Use a household cleaning spray or wipe, according to the label instructions. Labels contain instructions for safe and effective use of the cleaning product including precautions you should take when applying the product, such as wearing gloves and making sure you have good ventilation during use of the product.
- Seek medical attention: Seek prompt medical attention if your illness is worsening (e.g., difficulty breathing).
- Call your doctor: Before seeking care, call your healthcare provider and tell them that you have, or are being evaluated for, COVID-19.
- Wear a facemask when sick: Put on a facemask before you enter the facility. These steps will help the healthcare provider’s office to keep other people in the office or waiting room from getting infected or exposed.
- Alert health department: Ask your healthcare provider to call the local or state health department. Persons who are placed under active monitoring or facilitated self-monitoring should follow instructions provided by their local health department or occupational health professionals, as appropriate.
Call 911 if you have a medical emergency: If you have a medical emergency and need to call 911, notify the dispatch personnel that you have, or are being evaluated for COVID-19. If possible, put on a facemask before emergency medical services arrive.
- Stay at home until instructed to leave: Patients with confirmed COVID-19 should remain under home isolation precautions until the risk of secondary transmission to others is thought to be low.
- Talk to your healthcare provider: The decision to discontinue home isolation precautions should be made on a case-by-case basis, in consultation with healthcare providers and state and local health departments.
Frequently Asked Questions and Answers: Coronavirus Disease 2019 (COVID-19) and Pregnancy
Q: Are pregnant women more susceptible to infection, or at increased risk for severe illness, morbidity, or mortality with COVID-19, compared with the general public?
A: We do not have information from published scientific reports about susceptibility of pregnant women to COVID-19. Pregnant women experience immunologic and physiologic changes which might make them more susceptible to viral respiratory infections, including COVID-19. Pregnant women also might be at risk for severe illness, morbidity, or mortality compared to the general population as observed in cases of other related coronavirus infections [including severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV)] and other viral respiratory infections, such as influenza, during pregnancy.
Interim Guidance on breastfeeding for a mother confirmed or under investigation for COVID-19
Pregnant women should engage in usual preventive actions to avoid infection like washing hands often and avoiding people who are sick.
Q: Are pregnant women with COVID-19 at increased risk for adverse pregnancy outcomes?
A: We do not have information on adverse pregnancy outcomes in pregnant women with COVID-19. Pregnancy loss, including miscarriage and stillbirth, has been observed in cases of infection with other related coronaviruses [SARS-CoV and MERS-CoV] during pregnancy. High fevers during the first trimester of pregnancy can increase the risk of certain birth defects.
Q: Are pregnant healthcare personnel at increased risk for adverse outcomes if they care for patients with COVID-19?
A: Pregnant healthcare personnel (HCP) should follow risk assessment and infection control guidelines for HCP exposed to patients with suspected or confirmed COVID-19. Adherence to recommended infection prevention and control practices is an important part of protecting all HCP in healthcare settings. Information on COVID-19 in pregnancy is very limited; facilities may want to consider limiting exposure of pregnant HCP to patients with confirmed or suspected COVID-19, especially during higher risk procedures (e.g., aerosol-generating procedures) if feasible based on staffing availability.
Q: Can pregnant women with COVID-19 pass the virus to their fetus or newborn (i.e. vertical transmission)?
A: The virus that causes COVID-19 is thought to spread mainly by close contact with an infected person through respiratory droplets. Whether a pregnant woman with COVID-19 can transmit the virus that causes COVID-19 to her fetus or neonate by other routes of vertical transmission (before, during, or after delivery) is still unknown. However, in limited recent case series of infants born to mothers with COVID-19 published in the peer-reviewed literature, none of the infants have tested positive for the virus that causes COVID-19. Additionally, virus was not detected in samples of amniotic fluid or breastmilk.
Limited information is available about vertical transmission for other coronaviruses (MERS-CoV and SARS-CoV) but vertical transmission has not been reported for these infections.
Q: Are infants born to mothers with COVID-19 during pregnancy at increased risk for adverse outcomes?
A: Based on limited case reports, adverse infant outcomes (e.g., preterm birth) have been reported among infants born to mothers positive for COVID-19 during pregnancy. However, it is not clear that these outcomes were related to maternal infection, and at this time the risk of adverse infant outcomes is not known. Given the limited data available related to COVID-19 during pregnancy, knowledge of adverse outcomes from other respiratory viral infections may provide some information. For example, other respiratory viral infections during pregnancy, such as influenza, have been associated with adverse neonatal outcomes, including low birth weight and preterm birth. Additionally, having a cold or influenza with high fever early in pregnancy may increase the risk of certain birth defects. Infants have been born preterm and/or small for gestational age to mothers with other coronavirus infections, SARS-CoV and MERS-CoV, during pregnancy.
Q: Is there a risk that COVID-19 in a pregnant woman or neonate could have long-term effects on infant health and development that may require clinical support beyond infancy?
A: At this time, there is no information on long-term health effects on infants either with COVID-19, or those exposed to the virus that causes COVID-19 in utero. In general, prematurity and low birth weight are associated with adverse long-term health effects.
Q: Is maternal illness with COVID-19 during lactation associated with potential risk to a breastfeeding infant?
A: Human-to-human transmission by close contact with a person with confirmed COVID-19 has been reported and is thought to occur mainly via respiratory droplets produced when a person with infection coughs or sneezes.
In limited case series reported to date, no evidence of virus has been found in the breast milk of women with COVID-19. No information is available on the transmission of the virus that causes COVID-19 through breast milk (i.e., whether infectious virus is present in the breast milk of an infected woman).
In limited reports of lactating women infected with SARS-CoV, virus has not been detected in breast milk; however, antibodies against SARS-CoV were detected in at least one sample.
SART and ASRM Issue Advice for Infertility Patients Concerning the Novel Coronavirus (COVID-19)
Feb 20, 2020
Published in: ASRM Bulletin Vol 22, No 3
Currently the novel coronavirus (COVID-19) outbreak has been contained mostly to the Wuhan region of China, although there is growing evidence that the epidemic is spreading globally. It is important to note that at this point we are still learning about this virus and, for now, little is known about its impact on reproduction and pregnancy.
Therefore, out of an abundance of caution, the American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technologies (SART) suggest that individuals who are pregnant or seeking to initiate a pregnancy soon, avoid non-essential travel to known areas of infection or contact with potentially infected individuals. This advice applies to both men and women.
Patients, including prospective oocyte and sperm donors, as well as gestational carriers, who meet the diagnostic criteria for COVID-19 infection should avoid becoming pregnant. If they are undergoing active infertility treatment, we suggest that these patients consider freezing all oocytes or embryos and avoiding an embryo transfer until they are disease-free.
Furthermore, ASRM and SART are concerned that there may be intended parents who are using a gestational carrier to build their families whose travel may be restricted due to the virus, and who may then be unable to join their newborn in a timely manner. Consequently, we strongly encourage all intended parents and the legal professionals, organizations, and programs that facilitate these arrangements to promptly take the necessary steps to identify families that may be affected and develop contingencies in the event that these babies need to be cared for following their birth.
ASRM/SART member clinics who work with gestational carriers and intended parents are requested to reach out to their patients and those organizations and programs who facilitate gestational carrier arrangements to encourage them to ensure these steps are taken. Additionally, all reproductive health care professionals and their patients are encouraged to stay abreast of the latest guidelines and updates issued by the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) websites regarding evolving developments concerning the COVID-19 epidemic.
Additional information can be obtained at:
Practice Advisory: Novel Coronavirus 2019 (COVID-19)
The American College of Obstetricians and Gynecologists (ACOG) is closely monitoring the outbreak of a respiratory illness caused by a novel coronavirus (COVID-19) that was first detected in Wuhan City, Hubei Province, China, and continues to expand. Imported cases of COVID-19 infection in travelers have been detected in the United States, and person-to-person spread of COVID-19 also has been seen among close contacts of returned travelers from Wuhan. However, it is critical to note that at this time, for the general public in the United States, the immediate health risk from COVID-19 is considered low.
The Centers for Disease Control and Prevention (CDC) has released Interim Clinical Guidance for Management of Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) Infection and guidance for Evaluating and Reporting Persons Under Investigation (PUI).
Due to the current risk of COVID-19, the CDC recommends that travelers avoid all nonessential travel to the People’s Republic of China (this does not include the Special Administrative Regions of Hong Kong and Macau, or the island of Taiwan).
At this time, very little is known about COVID-19, particularly related to its effect on pregnant women and infants, and there currently are no recommendations specific to pregnant women regarding the evaluation or management of COVID-19.
Based on limited data and case examples from previous coronaviruses (SARS-CoV and MERS-CoV) and a small number of COVID-19 cases, it is believed that pregnant women may be at higher risk of severe illness, morbidity, or mortality compared with the general population (1-3). Adverse infant outcomes (eg, preterm birth) also have been reported among infants born to mothers positive for COVID-19 during pregnancy. However, this information is based on limited data and it is not clear that these outcomes were related to maternal infection. Currently it is unclear if COVID-19 can cross through the transplacental route to the fetus. There have been a few unsubstantiated reports of infants testing positive for the virus shortly after birth, but validated data is required to understand how these infants were infected and whether or not the virus can be transmitted during pregnancy. In limited recent case series of infants born to mothers infected with COVID-19 published in the peer-reviewed literature, none of the infants have tested positive for COVID-19 (1).
Obstetrician–gynecologists and other health care practitioners should obtain a detailed travel history for pregnant patients presenting with fever and acute respiratory illness and should follow the CDC’s Interim Clinical Guidance for Management of Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) Infection and guidance for Evaluating and Reporting Persons Under Investigation (PUI). Of note, health care practitioners should immediately notify infection control personnel at their health care facility and their local or state health department in the event of a PUI for COVID-19.
Infection Prevention and Control in Inpatient Obstetric Care Settings
The CDC has published Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings. These considerations apply to health care facilities providing obstetric care for pregnant patients with confirmed COVID-19 or pregnant persons under investigation (PUI) in inpatient obstetric health care settings including obstetrical triage, labor and delivery, recovery and inpatient postpartum settings.
The American College of Obstetricians and Gynecologists encourages physicians and other obstetric care practitioners to read and familiarize themselves with the complete list of recommendations.
Key highlights from the recommendations include:
- Health care practitioners should promptly notify infection control personnel at their facility of the anticipated arrival of a pregnant patient who has confirmed COVID-19 or is a PUI.
- Place a patient with known or suspected COVID-19 (ie, PUI) in an Airborne Infection Isolation Room (AIIR) that has been constructed and maintained in accordance with current guidelines. If an AIIR is not available, patients who require hospitalization should be transferred as soon as feasible to a facility where an AIIR is available.
- Infants born to mothers with confirmed COVID-19 should be considered PUIs. As such, these infants should be isolated according to the Infection Prevention and Control Guidance for PUIs.
- To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (eg, separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued.
- Discharge for postpartum women should follow recommendations described in the Interim Considerations for Disposition of Hospitalized Patients with COVID-19.
Due to the limited data on COVID-19, these recommendations are largely based on infection prevention and control considerations for other respiratory viruses such as influenza, SARS-CoV and MERS-CoV and are intentionally cautious as experts learn more about this new virus.
The CDC has developed Interim Guidance on Breastfeeding for a Mother Confirmed or Under Investigation for COVID-19. There are rare exceptions when breastfeeding or feeding expressed breast milk is not recommended. Whether and how to start or continue breastfeeding should be determined by the mother in coordination with her family and health care practitioners. Currently, the primary concern is not whether the virus can be transmitted through breastmilk, but rather whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding. A mother with confirmed COVID-19 or who is a symptomatic PUI should take all possible precautions to avoid spreading the virus to her infant, including washing her hands before touching the infant and wearing a face mask, if possible, while breastfeeding. If expressing breast milk with a manual or electric breast pump, the mother should wash her hands before touching any pump or bottle parts and follow recommendations for proper pump cleaning after each use. If possible, consider having someone who is well feed the expressed breast milk to the infant.
In limited case series reported to date, no evidence of virus has been found in the breast milk of women infected with COVID-19; however, it is not yet known if COVID-19 can be transmitted through breast milk (ie, infectious virus in the breast milk).
Precautions for Health Care Personnel
The CDC recommends that all health care personnel who enter the room of a patient with known or suspected COVID-19 (persons under investigation) should adhere to Standard, Contact, and Airborne Precautions. See the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) or Persons Under Investigation for 2019-nCoV in Healthcare Settings for detailed recommendations.
Currently, health officials are emphasizing that seasonal influenza remains a larger concern for the U.S. population. Influenza activity continues to be high across the United States, and health care practitioners are encouraged to continue offering influenza vaccine to their unvaccinated patients, particularly pregnant women. For more information on seasonal influenza and recommendations for pregnant women see the CDC’s website and ACOG’s Clinical Guidance.
The American College of Obstetricians and Gynecologists will continue to closely monitor the evolution of the 2019 novel coronavirus (COVID-19) in collaboration with the CDC. New and updated information will be shared as it becomes available.
This Practice Advisory was developed by the American College of Obstetricians and Gynecologists’ Immunization, Infectious Disease, and Public Health Preparedness Expert Work Group in collaboration with Laura E. Riley, MD; Richard Beigi, MD; and Denise J. Jamieson, MD.
- Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020; DOI: 10.1016/S0140-6736(20)30360-3. Available at: http://www.sciencedirect.com/science/article/pii/S0140673620303603. Retrieved Feb 21, 2020.
- Favre G, Pomar L, Musso D, Baud D. 2019-nCoV epidemic: what about pregnancies? Lancet 2020; DOI: 10.1016/S0140-6736(20)30311-1. Available at: https://www.sciencedirect.com/science/article/pii/S0140673620303111. Retrieved February 21, 2020.
- Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G, et al. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr 2020;9:51-60. Available at: http://tp.amegroups.com/article/view/35919/28274. Retrieved February 21, 2020.
- CDC Novel Coronavirus
- Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings
- CDC Evaluating and Reporting Persons Under Investigation (PUI).
- CDC CDC’s Interim Clinical Guidance for Management of Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV)
- CDC FAQs for Pregnant Women
- CDC Novel Coronavirus Information for Travelers
A Practice Advisory is issued when information on an emergent clinical issue (e.g. clinical study, scientific report, draft regulation) is released that requires an immediate or rapid response, particularly if it is anticipated that it will generate a multitude of inquiries. A Practice Advisory is a brief, focused statement issued within 24-48 hours of the release of this evolving information and constitutes ACOG clinical guidance. A Practice Advisory is issued only on-line for Fellows but may also be used by patients and the media. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal or incorporation into other ACOG guidelines.
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.
While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.
Publications of the American College of Obstetrician and Gynecologists are protected by copyright and all rights are reserved. The College’s publications may not be reproduced in any form or by any means without written permission from the copyright owner.
The American College of Obstetricians and Gynecologists (ACOG), is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. www.acog.org