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OBJECTIVE Fetal tissue research has driven significant medical advances but remains publicly contentious in the United States. The views of pregnant individuals in the United States regarding the donation of fetal tissue offer an important and previously unexplored perspective on this issue. METHODS We conducted a secondary analysis of data from two separate, broader qualitative studies. Pregnant and recently pregnant individuals (N=79) from clinical sites at the University of North Carolina at Chapel Hill, Johns Hopkins University, and Massachusetts General Hospital were interviewed individually using a semi-structured guide addressing a range of issues related to infectious disease research and pregnancy, including the acceptability of fetal tissue research. Interviews were transcribed, coded, and analyzed for emergent themes. RESULTS Among this sample of predominantly Black (61%), reproductive-aged pregnant and recently pregnant participants, the majority (72%) generally supported fetal tissue research. The following three themes were identified: choice, respect, and meaning. Respondents discussed the deeply personal nature of decisions surrounding fetal tissue research, emphasizing the importance of informed consent and respect for the person's emotional state when approaching for consent. The ways in which participants regarded how to respectfully handle fetal tissue also shaped views about the acceptability of donation, both for and against. For many participants, fetal tissue donation to research represented one way of ascribing meaning to pregnancy termination or loss. CONCLUSION Among this diverse sample of pregnant and recently pregnant individuals, most were supportive of fetal tissue donation for research. A better understanding of pregnant individuals' views on this topic may lead to policies and practices that are congruent with the needs and values of people facing decisions regarding the disposition of fetal remains.

Postpartum contraceptive decision making is complex, and recommendations may be influenced by breastfeeding intentions. While biologically plausible, concerns about the adverse impact of hormonal contraception on breast milk production have not been supported by the clinical evidence to date. However, the data have limitations, which can lead providers with different priorities around contraception and breastfeeding to interpret the data in a way that advances their personal priorities. Discrepancies in interpretations can lead to divergent recommendations for individual women and may cause conflict. Furthermore, providers must recognize that decision making about contraception and breastfeeding takes place in complex cultural, historical and socioeconomic contexts. Implicit bias may influence a provider's counseling. Unrecognized biases toward one patient or another, or one practice or another, may influence a provider's counseling. It is crucial for providers to strive to recognize their own biases. Providers need to respectfully recognize each patient's values and preferences regarding hormonal contraception and breastfeeding. Developing a patient-centered decision tool or implementing patient-centered interview techniques specifically around breastfeeding and contraception could help to minimize provider-driven variability in care.

The scientific and ethical importance of including women of reproductive age in biomedical research is widely acknowledged. Concerns about preventing fetal exposure to research interventions have motivated requirements for contraception among reproductive aged women in biomedical studies-often irrespective of risks and benefits or a woman's actual potential for pregnancy, raising important questions about when such requirements are appropriate. The perspectives of women themselves on these issues are largely unexplored. We conducted 140 interviews, 70 in the U.S. and 70 in Malawi, with women either living with or at-risk for HIV, exploring their views about the practice of requiring contraception in clinical trials. A majority of women interviewed from both countries indicated overall support for the practice, with seven themes characterizing advantages and disadvantages raised: reproductive control, health effects, prevention of fetal harm, burden on women, deferral to authority, autonomy regarding enrollment and birth control method, and relationship concerns. While women in the US frequently raised prevention of fetal harm as a key advantage, many other positives noted by women in both countries were related to contraception use in general, not specific to a trial context. With regard to disadvantages, U.S. women tended to focus on biomedical risks such as side effects and impact on fertility, whereas Malawian women focused on the social risks of contraception requirements, including violations of trust in marital relations and suspicions of potential infidelity. Given the potential benefits and burdens highlighted, contraception in research should be sensitive to actual fetal risk assessments; directed where justified at optimizing effective pregnancy prevention; responsive to women's reproductive preferences; and made available as an ancillary benefit even where risk thresholds do not justify requirement-in order to facilitate trials that are both ethical and robustly oriented around the interests and lives of women who will participate in them.

OBJECTIVE Ethical and counseling challenges are expected with the introduction of prenatal whole exome sequencing. In this study, we describe specific challenges identified through the UNC-Chapel Hill Prenatal Exome Sequencing Study. METHODS Participants were a subset of women participating in the fetal exome study, which has enrolled 73 mother-father-fetus trios in pregnancies diagnosed with structural anomalies and normal standard genetic testing results. In this descriptive study, cases were reviewed by members of the research team, including a bioethicist, to identify counseling challenges. Illustrative cases were chosen by group consensus. RESULTS Four illustrative cases were identified for further analysis. Challenges included need for adequate counseling and informed consent, challenges in prenatal variant interpretation, performing prenatal diagnosis in subsequent pregnancies, inability to identify a genetic etiology, and identifying parental secondary findings. CONCLUSION Our study illustrates several challenges identified in an ongoing prenatal exome study. While genomic medicine is a powerful tool for prenatal diagnosis, it is important that clinicians understand the ethical implications and parental perceptions of this testing modality.

Though many women in need of access to HIV preventive regimes are pregnant, there is a dearth of data to guide these care decisions. While oral pre-exposure prophylaxis (PrEP) has been shown to prevent HIV infection in numerous high-risk populations, pregnant women have been excluded from all major prospective trials. We propose for ethical examination a theoretical trial—a prospective, observational study of PrEP for pregnant women at risk for HIV in sub-Saharan Africa—highlighting an ethical tradeoff that characterizes issues faced for advancing research in pregnancy. On the one hand, an “opportunistic” study design has certain ethical advantages: as formally construed, the research activity usually begins after decisions to use PrEP during pregnancy are made in the clinical setting. This minimizes research risks and avoids ethical problems that a randomized controlled trial (RCT) comparing PrEP to placebo would entail, particularly withholding care proven beneficial in other populations. On the other hand, observational studies yield less precise information than RCTs. This raises a broader question about the pace of research with pregnant women, as it typically takes many years after a drug’s approval for use in the general population to determine safety of the medication in pregnancy. Such delays can have the effect of making it impossible to ethically conduct an RCT with pregnant women, reducing the likelihood that the research community is able to obtain robust, pregnancy-specific evidence. While an observational cohort is potentially the most ethically and scientifically justified research design to study PrEP in pregnancy, earlier involvement of pregnant women in studies of newer preventives may lead to evidence that is more timely and robust.

Disclosing harmful medical errors to patients is a prominent component of the patient safety movement. Patients expect it and safety agencies and experts advocate its implementation. Obstetrics presents unique challenges to carrying out disclosure recommendations: childbirth is a life-changing, emotionally charged, and dynamic family event characterized by high expectations and unpredictability, and perinatal care is provided by complex ad hoc teams in a litigious area of medicine. Despite these challenges, transparent communication with parents about unexpected adverse birth outcomes remains critical. We call on clinicians and professional societies to pursue a deeper understanding of the unique challenges of disclosure in obstetrics and prepare themselves to conduct these difficult conversations well.

To describe obstetrician-gynecologists' (ob-gyns') views and willingness to help women seeking abortion in a variety of clinical scenarios.We conducted a mailed survey of 1,800 U.S. ob-gyns. We presented seven scenarios in which patients sought abortions. For each, respondents indicated if they morally objected to abortion and if they would help patients obtain an abortion. We analyzed predictors of objection and assistance.The response rate was 66%. Objection to abortion ranged from 16% (cardiopulmonary disease) to 82% (sex selection); willingness to assist ranged from 64% (sex selection) to 93% (cardiopulmonary disease). Excluding sex selection, objection was less likely among ob-gyns who were female (odds ratio [OR] 0.5, 95% confidence interval [CI] 0.4-0.8), urban (OR 0.3, 95% CI 0.1-0.7), or Jewish (OR 0.3, 95% CI 0.1-0.7) compared with male, rural, or religiously unaffiliated ob-gyns. Objection was more likely among ob-gyns from the South (OR 1.9, 95% CI 1.2-3.0) or Midwest (OR 1.9, 95% CI 1.2-3.1), and among Catholic, Evangelical Protestant, or Muslim ob-gyns, or those for whom religion was most important, compared with reference. Among ob-gyns who objected to abortion in a given case, approximately two-thirds would help patients obtain an abortion. Excluding sex selection, assistance despite objection was more likely among female (OR 1.8, 95% CI 1.1-2.9) and United States-born ob-gyns (OR 2.2, 95% CI 1.1-4.7) and less likely among southern ob-gyns (OR 0.3, 95% CI 0.2-0.6) or those for whom religion was most important (OR 0.3, 95% CI 0.1-0.7).Most ob-gyns help patients obtain an abortion even when they morally object to abortion in that case. Willingness to assist varies by clinical context and physician characteristics.II.

Objective To describe fertility patients' preferences for disposition of cryopreserved embryos and determine factors important to these preferences. Design Cross-sectional survey conducted between June 2006 and July 2007. Setting Nine geographically diverse U.S. fertility clinics. Patient(s) 1020 fertility patients with cryopreserved embryos. Intervention(s) Self-administered questionnaire. Main Outcome Measure(s) Likelihood of selecting each of five conventional embryo disposition options: store for reproduction, thaw and discard, donate to another couple, freeze indefinitely, and donate for research; likelihood of selecting each of two alternative options identified in previous research: placement of embryos in the woman's body at an infertile time, or a disposal ceremony; importance of each of 26 considerations to disposition decisions; and views on the embryo's moral status. Result(s) We found that 54% of respondents with cryopreserved embryos were very likely to use them for reproduction, 21% were very likely to donate for research, 7% or fewer were very likely to choose any other option. Respondents who ascribed high importance to concerns about the health or well-being of the embryo, fetus, or future child were more likely to thaw and discard embryos or freeze them indefinitely. Conclusion(s) Fertility patients frequently prefer disposition options that are not available to them or find the available options unacceptable. Restructuring and standardizing the informed consent process and ensuring availability of all disposition options may benefit patients, facilitate disposition decisions, and address problems of long-term storage.

Deciding when and how to incorporate patient preferences regarding mode of delivery is challenging for both obstetric providers and policymakers. An analysis of current guidelines in four clinical scenarios (prior cesarean, twin delivery, breech presentation, and maternal request for cesarean) indicates that some guidelines are highly prescriptive whereas others are more flexible, based on physicians' discretion or (less frequently) patient preferences, without consistency or explicit rationale for when such flexibility is permissible, advisable, or obligatory. Although patient-choice advocates have called for more patient-responsive guidelines, concerns also have been raised, especially in the context of discussions of cesarean delivery on maternal request, about the dangers of unfettered patient-preference-driven clinical decisions. In this article, we outline a framework for the responsible inclusion of patient preferences into decision making regarding approach to delivery. We conclude, using this framework, that more explicit incorporation of patient preferences is called for in the first three scenarios and indicate why expanding access to cesarean delivery on maternal request is more complicated and would require more data and further consideration.

Objective To describe factors that affect infertility patients' decision making regarding their cryopreserved embryos. Design Forty-six semistructured in-depth interviews of individuals and couples participating in IVF programs. Setting Two major southeastern academic medical centers. Patient(s) Fifty-three individuals, including 31 women, 8 men, and 7 couples. Main Outcome Measure(s) Qualitative analysis of interview transcripts. Intervention (s) None. Result(s) Seven broad themes informed participants' decisions about embryo disposition: family and personal issues, trust, definition of the embryo, prospective responsibility to the embryo, responsibility to society, adequacy of information, and lack of acceptable disposition options. Many wished for alternative options, such as a ceremony at the time of disposal or placement of embryos in the woman's body when pregnancy was unlikely. Conclusion(s) Recent debates regarding embryo disposition do not reflect the range of values that infertility patients consider when deciding about frozen embryos. In addition to questions about the embryo's moral status, decision making about embryos is informed by a range of factors in the lives of individuals who created them. These perspectives may have important implications for the content and timing of informed consent, facilitating embryo disposition, and advancing policy debates about the ethics of frozen embryo use.

Objective To summarize the existing literature regarding the social implications of embryo cryopreservation and outline areas in need of further study. Result(s) The potential social impact of oocyte cryopreservation has not been investigated. Embryo cryopreservation has been increasingly used to improve the cost-effectiveness of in vitro fertilization (IVF) and expand the options available to infertile couples, yet its widespread adoption has occurred more rapidly than our ability to study the social consequences for the couples and health professionals involved. For maintaining cryopreserved embryos, the existing literature is fragmented and incompletely explores the effects on an infertile couple's psychosocial health and personal relationships, their family planning strategies, or their preferences for the disposition of the embryos. Managing unclaimed embryos continues to create challenges for assisted reproduction professionals. Conclusion(s) We currently lack a thorough understanding of the numerous social implications of cryopreservation. Major areas for future research include the impact of stored embryos on couples' fertility intentions and psychosocial health, factors that affect couples' decisions about embryo disposition, strategies to minimize unclaimed embryos, and the consequences of oocyte/ovarian cryopreservation.

BACKGROUND: Important clinical, social, and ethical questions are associated with the evaluation and use of surgical approaches aimed at correcting fetal anatomic abnormalities. In particular, the expansion of maternal-fetal surgery to ameliorate nonlethal fetal conditions has intensified the need to address issues about the adequacy of technology assessment and the safety of those who undergo these novel procedures. APPROACH: After discussions at a multidisciplinary conference, we reviewed the development and current practices of maternal-fetal surgery and analyzed the relevant ethical issues concerning the use of maternal-fetal surgery for nonlethal conditions, focusing on the correction of myelomeningocele. FINDINGS: Characterizing nonvalidated maternal-fetal surgery procedures as “innovative therapy” blurs the boundaries between research and therapy and creates uncertainty about the obligations of clinicians and researchers. Further, maternal-fetal surgery raises ethical issues related to maternal risks and benefits, informed consent, distinguishing lethal from nonlethal conditions, withholding unproven treatments, entrepreneurship, and prioritization. RECOMMENDATIONS: To help ensure that maternal-fetal surgery will be studied and eventually applied in a scientifically and ethically sound manner, we offer several recommendations. First, innovation in maternal-fetal surgery should be conducted and evaluated as research. Second, women must be considered research subjects in these trials. Third, the informed consent process must ensure adequate comprehension and genuine voluntariness in those considering participation. Fourth, discriminatory and fearful attitudes toward individuals with disabilities should be addressed explicitly prior to making a decision to proceed with maternal-fetal surgery in an attempt to correct such disabilities. Fifth, maternal-fetal surgery should not be performed for cosmetic indications unless and until there is reliable evidence that maternal-fetal surgery can be performed safely and that long-term side effects on women and their offspring are minimal. Sixth, centers of excellence should be established for conducting research and providing maternal-fetal surgery. Seventh, funding for research on maternal-fetal surgery should be considered in the context of societal needs.

Objective: To review the advances in the treatment of human immunodeficiency virus (HIV) infection and revisit the medical, ethical, and legal issues surrounding infertility management in HIV-infected couples. Design: Analytic review. Result(s): HIV infection continues to be a serious public health and reproductive issue. However, present policies which allow for the categorical exclusion of HIV-infected individuals from infertility services should be reconsidered in light of improvements in the prognosis of infected individuals and a dramatic decrease in the risk of vertical transmission. An analysis of the ethical cogency of the arguments against the provision of services does not substantiate the exclusion of HIV-infected individuals; rather, the principle of justice requires that HIV-infected women be treated the same way as a woman who might have an increased risk of conceiving a child with a disability or a may have a decreased life expectancy due to a chronic illness such as diabetes. Ethical disagreement notwithstanding, with the precedents recently established by the Americans with Disabilities Act (ADA), discrimination based on HIV status would also likely be unlawful under most circumstances. Conclusion(s): With advances in the treatment of HIV infection, contextualized counseling and a respect for patients' decisions regarding infertility treatment should be adopted as public policy. It is neither ethically nor legally justifiable to categorically exclude individuals from infertility services on the basis of HIV infection.

The lack of human data available to inform evidence-based treatment for illness during pregnancy has led to calls for greater inclusion of pregnant women in research, but the extent of their current representation is poorly characterized. Our objective was to measure the current exclusion of pregnant women from industry-sponsored clinical trials as a baseline for future comparison.We compiled data from studies enrolling women of childbearing potential posted on www.ClinicalTrials.gov between 1 October 2011 and 31 January 2012. The review was limited to open United States-based phase IV interventional studies sponsored by the pharmaceutical industry evaluating treatment of conditions that may be experienced by but are not limited to pregnant women and did not involve a medication classified as potentially teratogenic. If there was no mention of pregnancy in the inclusion or exclusion criteria, we contacted a study representative to confirm that pregnant women could be enrolled.Of 558 qualifying industry-sponsored studies, five (1%) were designed specifically for pregnant women. Of 367 phase IV clinical trials with verified inclusion and exclusion criteria, 348 (95%) excluded pregnant women and 19 (5%) did not.We found the exclusion of pregnant women from industry-sponsored clinical trials to be common practice. Moving beyond reflexive exclusion and developing thoughtful criteria for inclusion of pregnant women in clinical research would likely advance the evidence base to inform treatment decisions during pregnancy and lead to better health outcomes for women and children.

"Therapeutic" bed rest continues to be used widely, despite evidence of no benefit and known harms. In this commentary, we summarize the Cochrane reviews of bed rest and propose an ethical argument for discontinuing this practice. Cochrane systematic reviews do not support "therapeutic" bed rest for threatened abortion, hypertension, preeclampsia, preterm birth, multiple gestations, or impaired fetal growth. This assessment has been echoed in other comprehensive reviews. Prescribing bed rest is inconsistent with the ethical principles of autonomy, beneficence, and justice. Hence, if bed rest is to be used, it should be only within a formal clinical trial.

Our language both reflects and influences our attitudes and behavior. This Roundtable Discussion explores the language used in obstetrics and in the interactions between caregivers and women or their families: What do practitioners say to mothers and families during labor? At birth? In consultations? To describe what is happening? To encourage a woman's efforts? To lighten the atmosphere? When advising about possible interventions? Medical terminology in perinatal care can often be deceptive or confusing, not only for mothers but for caregivers. The authors of this Roundtable, representing health professionals from different specialties and interests in the field, have examined some examples of such language use, misuse, and abuse in perinatal care. (BIRTH 39:2 June 2012).

The concept of “normal birth” has been promoted as ideal by several international organizations, although debate about its meaning is ongoing. In this article, I examine the concept of normalcy to explore its ethical implications and raise a trio of concerns. First, in its emphasis on nonuse of technology as a goal, the concept of normalcy may marginalize women for whom medical intervention is necessary or beneficial. Second, in its emphasis on birth as a socially meaningful event, the mantra of normalcy may unintentionally avert attention to meaning in medically complicated births. Third, the emphasis on birth as a normal and healthy event may be a contributor to the long-standing tolerance for the dearth of evidence guiding the treatment of illness during pregnancy and the failure to responsibly and productively engage pregnant women in health research. Given these concerns, it is worth debating not just what “normal birth” means, but whether the term as an ideal earns its keep. (BIRTH 39:4 December 2012)

Fertility patients often struggle with decisions about disposition of embryos remaining after fertility treatment. We aimed to identify predictors and correlates of decisional conflict among patients facing these decisions.We analyzed results from a survey of 2210 patients from nine geographically diverse US fertility clinics. The main outcome measure was decisional conflict about embryo disposition, as measured by the decisional conflict scale (DCS).Of 1244 respondents who returned the survey, 1005 with cryopreserved embryos and DCS scores were included in the analysis. Of the respondents, 39% reported high decisional conflict (DCS ≥ 37.5). Thoughts about future childbearing were associated with high decisional conflict: respondents who were either uncertain about whether to have a baby in the future or sure they did not want to have a baby were at higher odds of high decisional conflict than participants who desired a baby [adjusted odds ratio (aOR) = 3.93, P0.001 and aOR = 1.69, P = 0.04, respectively]. Also associated with high decisional conflict were being likely to have embryos thawed and discarded (aOR = 2.08, P0.001), donated for research (aOR = 1.66, P = 0.01) or frozen 'forever' (aOR = 1.90, P = 0.01); being likely to choose compassionate transfer if it were available (aOR = 1.65, P = 0.03); attributing high, but not full, moral status to human embryos; not having enough information; and not being satisfied with the informed consent process.Decisional conflict about frozen embryo disposition differs according to reproductive preferences that may vary according to stage of treatment. Informed consent for embryo disposition should be revisited periodically, with serious discussions about disposition after childbearing is complete.

Determining approach to delivery after a previous cesarean is among the most contentious areas of obstetrics. We present a framework for ethically responsible guidelines and practice regarding vaginal birth after cesarean. We describe ethical complexities of 3 key issues that mark the debate: the cesarean delivery rate, safety, and patient autonomy. We then describe a taxonomy of considerations that should inform a responsible framework for guideline development and highlight critical distinctions between types of guidelines that have been blurred in the past. We then forward 2 central claims. First, in otherwise uncomplicated birth after a single previous cesarean, both vaginal birth after cesarean and repeat cesarean should be regarded as reasonable options; women, rather than policymakers, providers, insurance carriers, or hospitals, should determine delivery approach. Second, in complicated cases, providers and policymakers should carefully calibrate the strength of evidence to ensure differential risk and cost are adequate to justify directive guidelines given important variations in values women bring to childbirth.

Ethical decision making in women's health presents a series of unique challenges that are exacerbated considerably in under-resourced settings. Severe constraints on both autonomy and resources highlight limitations of principle-based ethics for addressing ethical dilemmas. Other useful ethical "tools" are considered in the context of 2 cases that emphasize the challenges to ethical decision making in under-resourced settings. The cases confront traditional notions of patient autonomy, highlight pervasive issues with regard to allocation of resources, and demonstrate the difficulties encountered in the careful application of medical ethics.

Patients making difficult choices among therapeutic options often ask their physicians what they would do if they were in the same situation. When faced with that question, physicians might be concerned that a direct answer could infringe on a patient's autonomy by substituting the physician's unique worldview or experience for their patients'. However, refusing to answer the question might lead a patient to feel unsupported at a difficult time. In this article we describe an approach that allows a physician to contribute to the patient's decision without inadvertently being coercive. That approach requires physicians to meaningfully shape therapeutic options, and assist patients in making difficult decisions. It is dependent on the physician being aware of the role of both their patients' values, and health values (eg, autonomy, futility) in decision making. It also requires an awareness of the force of language, both stated and implied, in shaping a patient's choice. To make a good decision, women need more than accurate information. They also need to be supported and sense empathy and understanding from their physicians and feel cared for. Although the facts (benefits and harms related to any given choice) are a necessary component of counseling, without discussion of values, they do not lead to a truly informed decision.

Assessing, communicating, and managing risk are among the most challenging tasks in the practice of medicine and are particularly difficult in the context of pregnancy. We analyze common scenarios in medical decision making around pregnancy, from reproductive health policy and clinical care to research protections. We describe three tendencies in these scenarios: 1) to consider the probabilities of undesirable outcomes alone, in isolation from women's values and social contexts, as determinative of individual clinical decisions and health policy; 2) to regard any risk to the fetus, including incremental risks that would in other contexts be regarded as acceptable, as trumping considerations that may be substantially more important to the wellbeing of the pregnant woman; and 3) to focus on the risks associated with undertaking medical interventions during pregnancy to the exclusion of demonstrable risks to both woman and fetus of failing to intervene. These tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants.

Maternal-fetal surgery for repair of fetal MMC is experimental treatment for which ethically justified clinical trials are not yet possible because equipoise is not established on medical or nonmedical grounds. We have focused here on only two of the important questions raised by this surgery. At least three others might have been considered. First is the question of access to the surgery. MMC is available only to those who can afford it. Given its poor results, that may be a good thing. However, if it were ever proved successful, it should be covered for the poor and affluent women who desire it. Second is the question of the autonomy of the women who seek the procedure. Although the women who undergo the surgery at Vanderbilt are counseled extensively by bioethicists, the autonomy of their decisions may be compromised by pressures from partners or others who think that any risk for the sake of a potential child is fully warranted. Third is the issue of potential discrimination against people with disabilities. Seeking or providing surgery that introduces the risk of fetal demise, a risk that could be avoided by postponing the surgery until after birth, suggests that life with disability is regarded as worse than death. Each of these questions deserves careful, critical analysis in its own right. Along with those addressed in this article, these issues are applicable to other ethical issues in perinatology, including those examined by other contributors to this issue.

Objective: We examined the attitudes of members of the Society for Maternal-Fetal Medicine regarding the clinical, scientific, ethical, and policy issues in maternal-fetal surgery. Study Design: A 43-question survey was distributed to all members of the Society for Maternal-Fetal Medicine. Two mailings and one electronic mail reminder were sent, each with instructions to submit the survey either via US mail or the Internet. The survey included questions in six categories: physician demographic data, experience with maternal-fetal surgery, views on innovative therapies, scientific validation of currently used and proposed procedures, ethical issues, and future directions in public policy. Results: Of the 1639 United States members sent questionnaires, 943 replied (response rate=59%). Forty-seven percent had referred patients for open fetal surgery for nonlethal conditions, and 69% believed physicians were obligated to inform patients of this option. Seventy-eight percent believed that innovative therapies should be performed only under institutional review board–approved protocols. Although the majority of respondents believed that certain proposed benefits of open fetal surgery for myelomeningocele could offset the risks, the majority (56%) also indicated that the procedure has not been validated. Fifty-seven percent believed that a moratorium should be imposed on open fetal surgery for nonlethal conditions, such as myelomeningocele, until a multicenter-controlled clinical trial is completed. Conclusions: The use of maternal-fetal surgery for nonlethal conditions is highly controversial. The majority of maternal-fetal specialists we surveyed support further research before such procedures are integrated into clinical practice. (Am J Obstet Gynecol 2001;185:1052-8.)