Academic literature on the topic 'American College of Obstetricians and Gynecologists. Women's Health Care Physicians'

We assessed neuroticism, perceived stress, and work-related factors among obstetrician-gynecologists (ob-gyns), and examined the relationships between these variables. Surveys were sent to 500 physician members of the American College of Obstetricians and Gynecologists and we received 287 (57.4%) completed responses. Analyses included descriptive statistics and linear regressions. Ob-gyns reported high levels of perceived stress. After controlling for neuroticism, variables that significantly predicted stress levels included average hours worked, perception of working too many hours, colleague support for work–home balance, isolation due to gender/cultural differences, and perception of workplace control. Because these work-related factors are linked to stress even when controlling for neuroticism, administrators and physicians may consider whether any of these factors are modifiable to mitigate physician stress. This in turn may affect physicians' own health and the quality of care patients receive.

Abstract Background The American College of Obstetricians and Gynecologists (ACOG) provides numerous narrative documents containing formal recommendations and additional narrative guidance within the text. These guidelines are not intended to provide a complete “care pathway” for patient management, but these elements of guidance can be useful for clinical decision support (CDS) in obstetrical and gynecologic care and could be exposed within electronic health records (EHRs). Unfortunately, narrative guidelines do not easily translate into computable CDS guidance. Objective This study aimed to describe a method of translating ACOG clinical guidance into clear, implementable items associated with specific obstetrical problems for integration into the EHR. Methods To translate ACOG clinical guidance in Obstetrics into implementable CDS, we followed a set of steps including selection of documents, establishing a problem list, extraction and classification of recommendations, and assigning tasks to those recommendations. Results Our search through ACOG clinical guidelines produced over 500 unique documents. After exclusions, and counting only sources relevant to obstetrics, we used 245 documents: 38 practice bulletins, 113 committee opinions, 16 endorsed publications, 1 practice advisory, 2 task force and work group reports, 2 patient education, 2 obstetric care consensus, 60 frequently asked questions (FAQ), 1 women's health care guidelines, 1 Prolog series, and 9 others (non-ACOG). Recommendations were classified as actionable (n = 576), informational (n = 493), for in-house summary (n = 124), education/counseling (n = 170), policy/advocacy (n = 33), perioperative care (n = 4), delivery recommendations (n = 50), peripartum care (n = 13), and non-ACOG (n = 25). Conclusion We described a methodology of translating ACOG narrative into a semi-structured format that can be more easily applied as CDS in the EHR. We believe this work can contribute to developing a library of information within ACOG that can be continually updated and disseminated to EHR systems for the most optimal decision support. We will continue documenting our process in developing executable code for decision support.

Background:Obstetrician—gynecologists are important providers of primary health care to women, and the hepatitis C virus (HCV) infection screening practices and recommendations provided by obstetrician—gynecologists for HCV-infected patients are unknown.Methods:We surveyed American College of Obstetricians and Gynecologists (ACOG) Fellows, including 413 Fellows who were participating in the Collaborative Ambulatory Research Network (CARN) and 650 randomly sampled Fellows, about HCV screening and counseling practices.Results:In total, 74% of CARN members and 44% of non-CARN members responded. Demographics and practice structure were similar between the two groups. More than 80% of providers routinely collected drug use and blood transfusion histories from their patients. Of the respondents, 49% always screened for HCV infection when patients had a history of injection drug use, and 35% screened all patientswho had received a blood transfusion before 1992. For HCV-infected patients, 47% of the physicians always advised against breastfeeding, 70% recommended condom use with a long-term steady partner, and 64% advised against alcohol consumption. Respondents who considered themselves to be primary care providers were no more likely to screen or provide appropriate counseling messages than were other providers.Conclusions:Most obstetrician—gynecologists are routinely collecting information that can be used to assess HCV infection risk, but HCV screening practices and counseling that are provided for those with HCV infection are not always consistent with current Centers for Disease Control and Prevention and ACOG recommendations.

Objective To evaluate the degree of adherence to the new the American College of Obstetricians and Gynecologists/Society for Maternal–Fetal Medicine guidelines in labor arrest management. Study Design A retrospective study of term, live, singleton deliveries with intrapartum primary cesarean delivery solely for failed induction of labor or labor arrest. Adherence was defined according to the Safe Prevention of the Primary Cesarean Delivery 2014 criteria. We evaluated adherence and compared maternal and perinatal outcomes, delivery time frame, and billing provider. Multivariable Poisson regression models with robust error variance were used to calculate adjusted relative risk (aRR) and 95% confidence interval (CI). Results Two-hundred six deliveries met the inclusion criteria; 73% were deemed not adherent to the guidelines. The majority of cases were under the care of nonacademic private practice OB/GYN physicians. The adherence rate was higher in the active phase of labor (45%) than in second stage (17%) and latent phase (14%). There were no differences in perinatal outcomes between the two groups. The adherence to guidelines was higher among academic OB/GYN physicians (aRR, 2.24, 95% CI, 1.49–3.36) and during the weekday–night shift (aRR, 1.81, 95% CI, 1.10–2.98). Conclusion Despite recent guidelines aimed to reduce the primary cesarean delivery rate, most cesarean deliveries performed for labor arrest disorders were not adherent to the guidelines.

Background: Iron deficiency anemia (IDA) is a multifaceted condition associated with immense obstetrical morbidity and mortality, and is especially prevalent in female patients of reproductive age.Abnormal uterine bleeding (AUB), which often manifests clinically as heavy menstrual bleeding (HMB), is the leading cause of IDA among reproductive age women in the United States, with a prevalence ranging from ~30-50% in this patient population; further, HMB is estimated to account for nearly one-third of all IDA causes worldwide. For these reasons, AUB/HMB is generally accepted as the primary causal source of IDA in daily clinical practice.As frontline clinicians who routinely manage HMB, OB/GYNs are optimally positioned to subsequently recognize, diagnose, and treat the IDA precipitated by HMB. However, to ensure the provision of safe and effective care, adaptive educational initiatives with an emphasis on evolving iron supplementation strategies are needed. Methods: Creative Educational Concepts (CEC) conducted a literature review, needs assessment, and detailed gap analysis to identify prominent clinical and educational gaps that exist among OB/GYNs with regard to IDA sign and symptom recognition, epidemiology, clinical gravity and risk factors, formal diagnosis, and appropriate treatment.Consequently, our team at CEC composed a responsive, multi-pronged educational design targeted to obstetricians, gynecologists, and women's health professionals, in a tailored effort to bridge the aforementioned gaps in current practice and improve outcomes for patients.CEC consulted with top experts in obstetrics and gynecology, maternal fetal medicine, pelvic surgery, and hematology at every stage of the educational design and delivery continuum, from proposal ideation to content development to live, on-site presentation.To dynamically engage the target audience, especially at the community, grassroots level, this educational initiative was delivered at a series of five American College of Obstetricians and Gynecologists (ACOG) District Meetings across the United States; live meetings were held in Lake Geneva, WI; San Diego, CA; Kapalua, HI; Rockport, ME; and Manhattan, NY. Results: 203 total clinicians were educated across the initiative Profession MD/DO - 93%APRN/CNM - 3%RN - 2%Other - 2%Specialty General OB/GYN - 81%Maternal/fetal Medicine - 11%Reproductive endocrinology - 4%Pelvic medicine/surgery - 2%Other - 2%>5,000 IDA patients potentially impacted per month as a result of the initiativeStatistically significant advances in learning and knowledge were achieved from pre- to post-activity for all tested educational gaps: Identification of IDA risk factors (85% post vs. 46% pre; P<0.001)Clinical implications of AUB (95% post vs. 74% pre; P<0.001)Appropriate clinical utility of IV iron (93% post vs. 63% pre; P<0.001)Top intended practice changes: Consider IV iron supplementation in my patients with IDA for whom oral iron supplementation is ineffective or intolerableConsider IV iron supplementation as first-line treatment for my patients with severe IDA, ongoing bleeding, and/or absorption deficienciesShare information learned with colleagues and other members of my healthcare teamTop anticipated barriers to change: Limited experience with parenteral iron supplementation therapiesPatient non-adherenceInadequate care coordination between OB/GYNs and primary care physiciansGiven an HMB-associated IDA patient case, activity attendees demonstrated a significant retention of knowledge and clinical performance improvement from pre-test to 4-week follow-up related to appropriate initiation of IV iron 90% at 4-wk follow-up vs. 63% at pre-test (P=0.018) Conclusions: Our 2019 ACOG District Meeting educational initiative precipitated substantive practice advances in knowledge, competence, and performance among OB/GYNs and women's health professionals related to IDA management.Statistically significant performance improvements in appropriate initiation of IV iron for treatment of HMB-associated IDA were achieved at follow-up assessment.Learning and knowledge endpoints for IDA risk factor recognition and AUB clinical implications were not retained with statistical significance at follow-up assessment, thereby evidencing residual educational gaps and a need for ongoing education in this space. Disclosures Shulman: Bayer: Consultancy; AMAG: Speakers Bureau; Lupin: Speakers Bureau; Vermillion: Speakers Bureau. Munro:Vifor: Consultancy; Abbvie: Consultancy, Research Funding; American Regent: Consultancy; Boston Scientific: Consultancy; Daiichi Sankyo: Consultancy. Martin:Daiichi Sankyo: Consultancy. Nelson:Merck: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Bayer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; AMAG: Consultancy; Agile Pharmaceutical: Consultancy, Research Funding; EvoFem: Research Funding; Sebela Pharmaceutica: Consultancy, Research Funding; TherapeuticsMD: Membership on an entity's Board of Directors or advisory committees; American Regent: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Abstract Background The American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women engage in at least 20 to 30 min of moderate-intensity physical activity on most days of the week. Regular exercise during pregnancy is associated with many benefits for the mother and the developing fetus; yet, a large number of pregnant women do not engage in the recommended amounts. This study aimed to investigate barriers to and interventions for physical activity among pregnant WIC participants in Southern California. Methods We conducted four focus groups (FGs) with pregnant low-income women aged 18 years or older in either their second or third trimester. FGs were conducted at a WIC center in Southern California. The FGs were held according to language (English vs. Spanish-speaking) and BMI category (normal weight vs. overweight and obese). A total of 28 women participated. We used ATLAS. ti. to analyze the focus group transcripts. The study adhered to the Consolidated Criteria for Reporting Qualitative Research. Results The mean age of focus group participants was 28.9 years (SD = 6.6), and the majority were Latina. Intrapersonal barriers to physical activity were fatigue and lack of energy, pain and swelling, lack of childcare, medical restrictions and safety concerns, lack of knowledge about exercise safety, and lack of time. Interpersonal barriers included concerns and lack of support from partners and families, conflicting advice from friends and neighbors, and lack of advice on safe exercise from physicians. Women in all four groups suggested a community-based intervention where they can mingle with each other and share their challenges and concerns. Other suggestions to interventions differed among groups and reflected the women’s experiences and backgrounds. Specifically, to promote education, English-speaking women preferred a brochure while Spanish-speaking women preferred a video. Overweight women emphasized including children in their exercise activities to promote healthy behavior in youth. Conclusions Interventions should be tailored to pregnant women’s needs. Primary care providers should provide reassurance and information to pregnant women and their partners on the type and frequency of safe exercise.

Photo by Anna Hecker on Unsplash
 ABSTRACT
 All people deserve the legal ability to outline their care decisions in advance and expect their decisions to govern during a pregnancy. However, until advance directives govern without pregnancy exceptions, people will not uniformly retain the ability to formulate autonomous decisions about their health care planning.
 INTRODUCTION
 In the last few years, states have passed increasingly restrictive laws regarding abortion and reproductive health care. Recent legislation in Alabama effectively banned the procedure altogether, while more than a dozen states have passed or are currently in the process of enacting so-called “fetal heartbeat laws,” which ban abortion at roughly six weeks post-conception after the detection of electrical activity in what could develop into fetal cardiac tissue.[1] While courts rarely uphold outright bans and broad sweeping legislation, they garner significant media and public attention.[2] In practice, however, often smaller legislative changes that garner the least attention have the most significant impact by steadily chipping away at healthcare rights. Few people realize the ethical impact of the poorly understood legal means by which a pregnant woman has already lost her right to make autonomous healthcare decisions over her body using an advance directive in nearly every state.
 BACKGROUND
 Advance directives are one of modern medicine’s most powerful yet underused tools. Most clinicians and patients think of advance directives as being only for the elderly or terminally ill. This association stems from the 1991 Congressional Patient Self-Determination Act that requires hospitals, nursing homes, and hospice agencies receiving federal funding to inform patients of their legal right to prepare an advance directive. The 2015 announcement by the Center for Medicare and Medicaid Services (CMS) to reimburse for advance directives without requiring a diagnosis code recognizes that all adult patients can benefit from advance directives regardless of illness or life expectancy.[3] Providers should be aware of a small but significant exemption found in most state advance directive laws. This exemption, commonly known as the pregnancy clause, invalidates the advance directive of a pregnant woman, negating autonomy. The pregnancy clause can lead to treatment against medical standards of care and places private interests over public health.
 Advance directive statutes are frequently amended, but currently, only eight states allow patients to write their pregnancy-related wishes into their advance directive and guarantee that their instructions will be followed. Eleven states automatically invalidate advance directives during pregnancy, while 18 states permit physicians to disregard a pregnant woman’s (or her proxy’s) wishes based on the likelihood of viability, pain, and suffering, or conscientious objector clauses. Thirteen states remain silent on whether an advance directive is binding during pregnancy or have contradictory statutes.[4] Viability has no standard definition for the purposes of the clauses and viability-based pregnancy clauses can lead to the same loss of rights as pregnancy clauses that invalidate advance directives due to pregnancy without any exceptions.
 Many may wonder about the clinical relevance of pregnancy clauses. The likelihood that a woman will need to effectuate an advance care directive while pregnant is higher than many people would realize. This situation is most commonly assumed to occur in instances of a brain-dead pregnant woman, of which there are a few cases reported each year. But brain death and persistent vegetative states are just two reasons to look to an advance directive. Advance directives more commonly apply to patients with dementia, strong religious objections to medical care, or during cancer treatments, surgery, or acute injury with temporary loss of capacity. In surgery or acute lapses of capacity, a proxy may be asked to make decisions if complications arise. The number of women potentially affected by pregnancy clauses is significant. Each year, 75,000 pregnant women will undergo non-obstetrical surgery;[5] one in 1,500 pregnant women will be diagnosed with cancer;[6] and an estimated 250,000 Americans will exhibit early-onset Alzheimer’s symptoms between the ages of 30 and 50.[7]
 ANALYSIS
 Though pregnancy clauses are a seemingly narrow focus, they can nullify an entire advance directive and restrict care not related to the fetus. By negating entire advance directives, the clauses negate proxy appointments, allowing decision-makers other than the intended proxy. Providers and proxies are left with little guidance over who can make decisions on behalf of the patient. Many states will appoint a biological family member as the surrogate decision maker if there is no designated proxy or the directive is invalid. The outdated language and assumptions about nuclear families found in these structures could significantly impact unmarried couples, same-sex partnerships, and relationships that do not meet state-defined partnership standards where the courts may appoint someone other than the woman’s significant other even when she designated them as a proxy.[8] Members of religious groups whose doctrines prohibit certain medical therapies must be informed that if they become pregnant, their autonomous ability to decide about medical care through an advance directive and their right to freely practice religion can be voided entirely.
 In addition to infringing on patient autonomy, pregnancy clauses also restrict how clinicians might practice medicine by mandating medically inappropriate treatments against the provider’s recommendations. For example, Illinois’s pregnancy clause stipulates that “if you are pregnant and your health care professional thinks you could have a live birth, your living will cannot go into effect.”[9] This clause places providers in a difficult position of sacrificing their therapeutic obligation to their patients. It may require them to use futile therapy against the patient’s best interest and without regard for prolonged pain and suffering.
 Pregnancy clauses are void of any consideration of the best clinical interest of the patient or the fetus and instead promote conservative rhetoric that all potential fetal life is paramount. Numerous medical and chromosomal conditions are incompatible with life or present significant potential disabilities that may be accompanied by pain and suffering. The same conditions also pose risks to the mother, including death. Accordingly, the medical profession recognizes that there are instances in which it may not be in the best medical interest of the mother or the fetus to continue the pregnancy. Yet providers are seemingly required by pregnancy clauses to violate codes of conduct and subject pregnant patients and their nonviable fetuses to treatments to which other patients would not be subjected.
 Without evidence of a patient’s clear and convincing intentions, states have an interest in protecting life, preventing suicide, and maintaining the ethical integrity of the medical profession that could interfere with the person’s ability to refuse care.[10] The legal defense of pregnancy clauses is that the state’s interest in fetal life is sufficiently important to override the mother. As established in Planned Parenthood v. Casey (1992), however, the state’s interest only exists for fetal life post-viability.[11] Therefore, to allow the state interest to override the person’s advance directive when the fetus is not yet viable violates Casey.
 Individuals have a legal and ethical interest in maintaining bodily privacy, integrity, and freedom from unwanted touching. They have the right to appoint a proxy or use a directive to govern care in the case of incapacity. Even when contemplating brain death, organ donation, and whether to be cremated or buried, there is an expectation that personal wishes will govern. Honoring an advance directive allows providers to uphold the integrity of the medical profession by respecting the principles of autonomy and beneficence. Pregnancy clauses are inherently unethical as their creation was not to further the integrity of the medical or legal profession, nor protect a state’s interest in the patient’s life. In 2016, the American College of Obstetricians and Gynecologists issued a committee opinion that pregnancy is not an ethical exemption to the right of capable patients to refuse treatment.[12] The right to direct treatment while pregnant is consistent with modern medical practice, while the legislative promotion of a singular abstract interest in potential fetal life to the exclusion of all other medical and ethical considerations is not in line with the profession’s values.[13]
 Many pregnancy clauses are politically motivated, reflecting anti-abortion legality lobbying efforts and attempts to win over conservative voters. When Alaskan Attorney General Harold M. Brown argued the state’s pregnancy clause was unconstitutional, Governor Bill Sheffield – a Democrat in a historically red state – enacted the bill anyway. Georgia’s Governor Bill Kemp narrowly won his election, with some crediting his aggressive messaging against immigration and abortion.[14] With either advance directives, proxies, or even friends and relatives who know what the person (if not incapacitated) would have wanted, courts and legislatures should not have leeway to force care that a person, if conscious, would have refused.[15]
 The ability to harness advance directive law to force invasive and unwanted treatment upon a pregnant patient’s body continues to occur out of the fear of legal uncertainty. The lack of uniformity between states in their pregnancy clauses further adds to the confusion. Many advance directive statutes create a conditional proposition: if a provider acts in accordance with the carefully drawn circumstances of an advance directive, the provider is granted protective immunity from accusations of malpractice or wrongful death for that conduct. It is neither illegal nor unethical to remove a ventilator, for example, from a patient who has directed such a course of action in an advance directive. A pregnancy clause may remove that immunity making the unethical act of ignoring the directive legal, but the ethical act of following it (removing a ventilator, for example) could subject the practitioner to liability.[16] Without a pregnancy clause, providers retain the ability to both follow an advance directive and to act in the best medical interest of their patient. Pregnancy clauses create confusion over the permissibility of medical acts in an attempt to coerce providers into making decisions that violate the rights of their patients and their own ethical codes of conduct.
 Pregnancy clauses are a fallacy of consequentialist ethics in which the morality of the outcome justifies actions. Under consequentialist reasoning, any violation to the woman is justified if the fetus develops and results in a live birth. This reasoning is further faulty as it incorrectly assumes that mechanically ventilating an unconscious, sick, dying, or dead body will result in a live birth. Consequentialist theories should be limited to situations with predictable ends. Ethical medical providers refute consequentialism in certain contexts because it treats patients as a means to an end to produce benefit for others. In pregnancy, ignoring advance directives to achieve the chance that a fetus might survive is not justified by consequentialism.
 Pregnancy clauses also fail through the lens of deontological ethics in which an action must be ethical in and of itself and not based on outcomes. The choice to respect autonomy through an advance directive should be followed uniformly absent special circumstances. Proponents of pregnancy clauses may argue that pregnancy is an appropriate exception because a woman “has chosen to lend her body to bring [a] child into the world.”[17] Minnesota and Oklahoma echo this belief in their statutes, which contain an unjustified rebuttable presumption that all female patients would want life-sustaining treatment if they are pregnant.[18] Pregnancy should not abrogate the rights of a person to assign a proxy for access to an abortion or to control her medical treatment. Pregnancy exclusions are not grounded in the ethical “best interest” standards for the mother or the fetus. Instead, they are rooted in outdated expectations of female gender roles, which reaffirm a legislative assumption that a pregnancy is more morally valuable than a woman’s autonomy.
 CONCLUSION
 All people deserve the legal ability to outline their care decisions in advance and expect their decisions to govern during a pregnancy. Providers and the government do not have to approve of a person’s care decisions or values, but medical practitioners must respect a person’s right to dictate their own health narratives.
 With the push for more patients to execute advance directives, providers and patients must be aware that their advance directives may succumb to the authority of pregnancy clauses. Until advance directives govern without pregnancy exceptions, people will not uniformly retain the ability to formulate autonomous decisions about their health care planning. Advance directive law will continue to be hijacked by politically motivated legislators. When seeking to address inequities in healthcare laws and access, it is essential to take a closer look at not only the headline cases but also the clauses and exemptions to laws seemingly designed to benefit patients.
 [1] For proposed and current abortion legislation and maps, see https://www.guttmacher.org/state-policy# and Anne Godlasky, Nicquel Terry Ellis, and Jim Sergent, “Where is Abortion Legal? Everywhere, but…” USA Today, May 15, 2019, updated April 23, 2020 https://www.usatoday.com/in-depth/news/nation/2019/05/15/abortion-law-map-interactive-roe-v-wade-heartbeat-bills-pro-life-pro-choice-alabama-ohio-georgia/3678225002/
 [2] https://www.guttmacher.org/state-policy# (Many bills fail in legislatures and are not enacted.)
 [3] Department of Health and Human Services Centers for Medicare & Medicaid Services; 42 CFR Part 405, 410, 411, 414, 425, and 495; “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016; Final Rule.”
 [4] DeMartino, E. S., Sperry, B. P., Doyle, C. K., Chor, J., Kramer, D. B., Dudzinski, D. M., & Mueller, P. S. (2019). US State Regulation of Decisions for Pregnant Women Without Decisional Capacity. JAMA, 321(16), 1629–1631. https://doi.org/10.1001/jama.2019.2587; Villarreal, Elizabeth. “Pregnancy and Living Wills: A Behavioral Economic Analysis.” The Yale Law Journal Forum. Vol. 128 (2019); 1052-1076.
 [5] “Surgery During Pregnancy.” Intermountain Healthcare: Fact Sheet for Patients and Families,
 (2018). https://intermountainhealthcare.org/ext/Dcmnt?ncid=520782026
 [6] Basta, P. Bak, A. Roszkowski, K. “Cancer Treatment in Pregnant Women”. Contemporary
 Oncology, 19, no. 5 (2015): 354–360
 [7] “31-Year-Old Woman Fights Alzheimer's While Pregnant.” San Francisco Globe. 9 July 2015,
 sfglobe.com/2015/02/19/31-year-old-woman-fights-alzheimers-while-pregnant.
 [8] “Health Care Proxies.” Human Rights Campaign, https://www.hrc.org/resources/health-care-proxy.
 [9] Illinois Department of Public Health website, Statement of Illinois Law on Advance Directives and DNR Orders, http://www.idph.state.il.us/public/books/advdir4.htm.
 [10] In the Matter of Karen Quinlan, 355 A.2d 647 (1976); Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990); and In re Conroy 486 A.2d 1209 (1985).
 [11] Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992).
 [12] The American College of Obstetricians & Gynecologists Committee on Ethics, Committee
 Opinion No. 664: Refusal of Medically Recommended Treatment During Pregnancy, (2016).
 [13] Lederman, Anne D. “A Womb of My Own: A Moral Evaluation of Ohio’s Treatment of Pregnant Patient’s with Living Wills”. Case W. Res. L. Rev. Vol. 45:351 (1995); 351-377.
 [14] Tavernise, Sabrina. “The Time Is Now: States Are Rushing to Restrict Abortion, or to Protect It.” The New York Times, 15 May 2019.
 [15] Cruzan.
 [16] Mayo, T.M. “Brain-Dead and Pregnant in Texas.” The American Journal of Bioethics, Vol. 14, no. 8 (Nov. 2014); 15-18.
 [17] In re A.C., 573 A. 2nd 1244 (1990).
 [18] Johnson, Kristeena L. “Forcing Life on the Dead: Why the Pregnancy Exemption Clause of the Kentucky Living Will Directive Act is Unconstitutional.” Kentucky Law Journal. Vol. 100 (2011-12); 209-233.