34 domains. Every system shaping women's health.

Homicide is the leading cause of pregnancy-associated death — 3.62 per 100,000, exceeding every obstetric cause combined by more than twofold; 68% involve firearms. Screen for intimate partner violence at every prenatal visit and document it as part of the social history. Ask with the partner out of the room, and know your same-day DV referral pathway before you need it.

Homicide is now the leading pregnancy-associated cause of death. Screen clients at intake and the first visit; out-of-hospital birth carries additional risk if IPV is present. Partner with local DV agencies for warm referrals, and build IPV screening + documentation into your charting. If a client discloses, believe her and connect her to help the same day.

Homicide is the #1 killer of pregnant people, and 68% of these deaths involve a firearm. You are often the trusted person a client talks to first. Watch for controlling partner dynamics — a partner who answers every question, controls the phone, won’t leave the room. Listen without judgment, keep local DV hotlines, shelters, and legal-aid numbers ready, and if a client discloses abuse, believe her and connect her to help.

Maternal homicide is the leading cause of pregnancy-associated death (3.62 per 100,000 live births), and it disproportionately kills young Black women — those 18–24 die at four times the national rate. Develop mandatory IPV screening protocols, staff training, social-work integration, private screening space, and trauma-informed care standards.

If you are pregnant or know someone who is: homicide is now the #1 cause of death during pregnancy and the year after birth. Most of these deaths involve abuse in a relationship, and most involve a gun. If you feel unsafe, tell a doctor, nurse, midwife, or doula. There are free, confidential hotlines (1-800-799-7233) and shelters. You deserve to be safe.

Syphilis screening is non-negotiable at every prenatal entry point. If your state doesn’t mandate third-trimester rescreening, do it anyway — in 2024 every state qualifies. Know your Bicillin supply status this week, not last month. If supply is zero, have your ceftriaxone alternative protocol written and approved before you need it. Document every treatment delay caused by drug shortage.

Order RPR at the first midwifery visit regardless of risk profile — universal screening is the standard. If a client tests positive, this is an immediate physician referral for same-day treatment, not a “rescreen in 4 weeks” situation. If you’re in a birth center without injection capability, have a standing agreement with the nearest clinic that stocks Bicillin. Every week of delay increases vertical transmission risk.

You’re not diagnosing or treating, but you can close the gap. If your client mentions she hasn’t had her “blood work” done, that’s your opening: “Have you been screened for syphilis? It’s a simple blood test and the treatment is one shot.” Normalize the conversation — syphilis carries stigma that keeps people from asking. Keep the number for your local health department STI clinic in your phone.

Pull your congenital syphilis numbers for the last 3 years. If they’re rising, you have a system failure in prenatal screening completion. Audit: what percentage of pregnant patients received all three recommended syphilis screens? What’s your time-to-treatment for positive results? How many days of Bicillin supply do you have on hand right now? Advocate for emergency Bicillin production authorization.

The treatment is one shot. One injection, $30, given during a routine prenatal visit, and the baby is born healthy. But the drug isn’t on the shelf. The appointment wasn’t made. The screen wasn’t ordered. And a baby is born blind, with bone fractures, or not born at all — because a disease we’ve known how to cure since 1943 outran a supply chain that nobody was watching.

The pre-Dobbs legal framework you trained under no longer exists. Your clinical decision-making in reproductive health is now shaped by your state’s criminal code. In a ban state, every emergency exception decision could be reviewed by a prosecutor — get personal legal counsel. In a non-ban state, expect sicker patients from across state lines. If you’re considering relocation, ACOG reports accelerating attrition from ban states.

Your scope in reproductive health is now defined not just by your state’s practice act but by its abortion statute. In ban states, even miscarriage management may draw legal scrutiny if a prosecutor questions whether the loss was spontaneous. Document meticulously and contemporaneously — clinical findings, imaging, labs, patient-reported history. In non-ban states, prepare for an expanded caseload as patients seek care across borders.

Your clients in ban states are scared, and they should be. Your role is grounding: be present, provide accurate information about their state’s law (not legal advice), and connect them to legal resources. National Advocates for Pregnant Women (212-255-9252) provides legal support; If/When/How runs a repro legal helpline.

The post-Dobbs landscape creates three risk categories: criminal liability for providers in ban states, capacity strain in receiving states, and workforce attrition. Assess which applies. Ban states: legal review of all reproductive-health protocols, a provider legal-defense mechanism, attrition tracking. Receiving states: model the volume increase, budget for capacity, plan recruitment from departing ban-state providers.

For 49 years, if a state tried to ban abortion entirely, the Supreme Court said no. Then, in June 2022, the Court said yes. Not a different Court — the same institution, in the same building, interpreting the same Constitution. Fourteen states banned abortion within 100 days. The guardrail didn’t bend. It disappeared.

Call your pharmacy right now. How many vials of Bicillin L-A do you have? If the answer is fewer than 10, you are one positive RPR away from a clinical crisis. Build your rationing protocol before the situation forces one on you. Document every case where treatment was delayed by supply. Know your ceftriaxone alternative: 1g IV daily for 10–14 days, with desensitization for penicillin allergy and ID consultation.

You cannot treat syphilis in a birth center. Your job is to screen universally and refer immediately — but “immediately” means knowing which clinic in your region actually has Bicillin this week, not assuming the hospital pharmacy does. Call ahead. Maintain a weekly-updated list of local treatment sites with confirmed supply, and walk positive referrals through personally.

You’ll hear about this from your clients before the news does: “They said I have syphilis but they don’t have the medicine.” That’s real, and it’s terrifying. Validate the fear, then problem-solve: call the state health department STI hotline (many maintain a supply locator), connect your client to the nearest confirmed treatment site, and document the gap so someone can count it.

Quantify your exposure: how many syphilis-positive pregnant patients did your system see in the last 12 months? Multiply by your current Bicillin stock. If the ratio is below 50%, you are in crisis. Escalate to your CMO and state health officer, advocate for emergency production under the Defense Production Act, and publicly report every adverse neonatal outcome attributable to treatment delay.

The pharmacist tells the doctor: “We have two vials left.” There are three pregnant women with positive syphilis tests this month. The doctor has to choose. Not which treatment to use — which patient gets treated at all. This isn’t a developing-country scenario. This is Minnesota, 2025.

Your late-entry prenatal patients are going to spike. Compress the first-visit workup (labs, dating scan, risk assessment) into a single visit. Screen for preeclampsia, gestational diabetes, and syphilis same-day. Document carefully — these patients may not return. Consider extended-hours or walk-in prenatal slots designed to reduce barriers.

Community-based midwifery is uniquely positioned to reach this population. Offer home-visit prenatal care where legal. Build trust by partnering with immigrant-serving organizations. Make your intake visibly safe — no SSN requirement, no ID photocopying, no ICE-cooperation signage. Your continuity-of-care model is exactly what these families need.

Your immigrant clients may stop answering the phone after a workplace raid or ICE news cycle. Don’t interpret silence as disengagement — it’s fear. Proactively text in their preferred language: “I’m here when you’re ready. Your visit is private.” Know your local sanctuary clinics by name, and keep a list of free/sliding-scale prenatal providers who don’t ask about status.

Audit your facility’s data-sharing policies immediately. Does your EHR collect immigration status? It shouldn’t. Does billing report to any federal database that could be cross-referenced? Review MOUs with law enforcement. Institutions that publicly declare sanctuary status see measurably higher utilization among immigrant populations; the liability of non-declaration is unscreened patients presenting in crisis at L&D.

She’s 32 weeks pregnant and hasn’t seen a doctor since the positive test. Not because she doesn’t want prenatal care — she wants it desperately. But last month, ICE arrested a man in the parking lot of the clinic two blocks from her apartment. Now the clinic might as well be on the moon. When she finally shows up at the ER in labor, her blood pressure is 180/110 and nobody knows she’s preeclamptic.

Your clinical outcomes are being shaped by policies you didn’t write but must respond to. A patient at 34 weeks with no prior prenatal care, undiagnosed preeclampsia, and a BP of 170/105 is not a “late presenter” — she is a patient who was too afraid to come in. Assume missed screenings, order the full prenatal panel same-day, and prepare for higher-acuity deliveries. Document the pattern — your data is the evidence base.

Community midwifery practices in immigrant neighborhoods are front-line responders. Offer home visits where your scope allows — you remove the clinic-as-surveillance-site barrier entirely. Build relationships with trusted intermediaries (churches, mutual-aid networks, ESL programs). Your continuity model is evidence-based and fear-reducing; use it intentionally.

You may be the only person in your client’s pregnancy she trusts enough to tell the truth about why she hasn’t been to the doctor. When she says “I couldn’t get an appointment,” listen for “I was afraid.” Don’t push — affirm, then connect: “I know a clinic where they don’t ask about papers. Can I take you there?” Keep a current list of sanctuary and free prenatal clinics.

The BJOG review gives you the evidence base to act. Pull your data: which immigrant-serving zip codes show late-entry prenatal rates above the state average, and how do preterm birth rates track there? If they diverge from your general population, you have a policy-generated disparity. Declare sanctuary status, remove immigration-status fields from EHR intake, and host know-your-rights workshops. Earlier prenatal care = fewer NICU admissions = lower cost.

Twenty-four studies. Twenty-nine examined, twenty-four confirmed the same thing: when a country tells pregnant women they might be deported, those women stop going to the doctor. Not because they don’t want care — because they’re choosing between a prenatal visit and keeping their family together. The babies pay the price — born too early, born too small, or not born at all.

Know your state’s law to the letter — exception language, reporting requirements, criminal penalties. In a ban state, your emergency exception decisions will be scrutinized; document clinical reasoning in real time, not retrospectively. In a receiving state, prepare for higher-acuity patients at later gestational ages with more complex needs, and staff accordingly.

In ban states your scope does not include abortion provision, but your role in contraceptive counseling, early pregnancy assessment, and timely referral is critical — know which out-of-state facilities accept your referrals. In receiving states, expect patients who delayed care due to legal confusion; be prepared for higher-risk presentations in your prenatal panels.

Your clients in ban states may ask you, quietly, where they can go. You are not a medical provider and not giving medical advice — but you can share publicly available information. Know the National Abortion Federation Hotline (1-800-772-9100) and regional practical-support organizations by name. Never put anything in writing that could be subpoenaed. Support with presence, not paper trails.

Model the volume impact. Receiving-state hospital: how many out-of-state patients has your OB/GYN department seen in 12 months, and what’s the impact on OR time, clinic slots, and burnout? Budget for it. Ban state: what’s your legal exposure for emergency exceptions? Have outside counsel review protocols, and track every out-of-state transfer — that data will be needed when legislatures revisit these laws.

She drives nine hours across two state lines to reach a clinic that will see her. She’s 14 weeks — past the point where a simple procedure works. She was 8 weeks when she made the appointment, but the wait was six weeks because the clinic is absorbing patients from three banned states. The delay didn’t come from indecision. It came from geography.

You are practicing in a legal environment designed to make you hesitate. Do not hesitate when a patient is clinically deteriorating. Document in real time with objective clinical language: “Patient’s condition is deteriorating with evidence of [specific findings].” Know your state’s mandatory reporting triggers. Have personal legal counsel on retainer — not a future plan, a current arrangement.

Your scope in ban states does not include uterine evacuation, but you may be the first provider to identify an ectopic pregnancy, incomplete miscarriage, or previable PPROM. Your documentation and referral speed are critical — time to treatment may determine whether a patient develops sepsis. Know your transfer pathway by name and number, and document vital signs, presentation, and time of recognition. Your chart note may be a legal exhibit.

You may witness your client being denied care in real time — a doctor saying “We have to wait until she’s sicker.” That is not the doctor’s choice; it’s the law’s constraint on the doctor. Document what you observe (without practicing medicine), provide emotional support, and connect the patient to legal resources if she wants them. National Advocates for Pregnant Women: 212-255-9252.

Your legal exposure is significant and growing. Ensure your counsel has reviewed emergency-exception protocols within the last 90 days; your OB/GYN department has written decision-support algorithms (ectopic, PPROM, septic abortion) aligned with your state’s specific exception language; you are tracking provider attrition; and you have a provider legal-defense fund or insurance supplement in place.

The ER doctor knows the patient has an ectopic pregnancy. She knows the treatment. She’s done it hundreds of times. But tonight she pauses — calls the hospital attorney first. While she waits for a callback, the fallopian tube ruptures. The patient nearly bleeds to death on the table. The doctor saved her life. The state may still prosecute her for it.

Assume every reproductive-health visit generates a digital trail. In restrictive states, counsel patients verbally on privacy — not in the chart, not in the portal: leave the phone in the car, pay cash, don’t search for the clinic on a personal device. Know your state’s subpoena landscape — has your AG already pursued reproductive-health records? Talk to your CMO and legal counsel before a subpoena arrives.

Your home-visit and birth-center model generates fewer institutional data points than a hospital visit — a concrete privacy advantage you can name to patients. But protect your own data: your phone’s location history at the client’s home is subpoenaable. Use a work phone with location services disabled during sensitive visits, and encrypted messaging (Signal) for reproductive-health communication.

Everything you text, Venmo, post, or search is potentially discoverable. If you are supporting clients accessing care in a restricted state: use Signal, not iMessage; cash, not Venmo; verbal directions, not shared map links. This isn’t paranoia — it’s operational security, and in at least three states digital evidence has already been used in reproductive-health investigations.

Commission a reproductive-health data-privacy audit. Inventory every system capturing patient-identifiable data tied to reproductive-health visits — EHR, billing, parking, WiFi, security cameras, visitor logs, pharmacy. For each: what’s the retention period, who has access, what’s the subpoena-response protocol? If you can’t answer for every system, you have unknown liability. Engage health-privacy counsel and stand up a subpoena-response team before you receive one.

She searched “abortion clinic near me” on Tuesday. On Wednesday, her phone pinged a cell tower near the clinic in the next state. On Thursday, her Venmo showed a $50 payment to an abortion fund. On Friday, a subpoena arrived at the fund demanding her name. The law that made all of this possible was written in 1873, when the most advanced surveillance technology was a postal inspector opening an envelope.

This is a workplace-safety issue, not just a societal concern. Your clinic is a gender-concentrated space that incel ideology explicitly targets. Ensure functioning panic buttons in every exam room, a lockdown protocol staff have rehearsed, and a law-enforcement relationship that includes threat briefings. If a patient’s companion makes hostile or controlling statements about women, take it seriously as a safety signal — for the patient and your staff.

Birth centers and home-visit practices have different security profiles than hospitals — often less physical security but more isolation. Ensure your birth center has a rehearsed lockdown protocol. For home visits: if a client’s partner exhibits hostility toward women, controlling behavior, or references to online extremist content, include it in your safety assessment, and keep a check-in protocol with a colleague.

You work in intimate spaces with vulnerable women, often alone. Trust your instincts about threatening situations. If a client’s partner makes you feel unsafe — controlling behavior, hostility toward women, references to online ideology — you are not overreacting. Have an exit plan for every home visit, keep your phone charged and location shared with a colleague, and report threatening behavior to the care team.

Add incel-motivated violence to your facility threat matrix — ISD’s research documents active radicalization pipelines, and healthcare settings match the targeting profile (gender-concentrated, publicly accessible, symbolic). Assess: are your OB/GYN and women’s-health locations physically secure with separate entrances? Are security staff trained on gender-targeted-violence indicators? Budget for threat assessment and physical-security upgrades specific to women’s-health service lines.

In a forum with 40,000 members, a man posts a detailed fantasy about attacking women at a clinic. Other members reply with encouragement. One calls him “based.” Another posts the address of a real OB/GYN office. The post stays up for weeks. The forum’s terms of service prohibit “advocating violence.” Nobody enforces them. The next attacker is reading.