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April 2, 2003

The Maternal-Fetal Relationship

JAMA. 2003;289(13):1696. doi:10.1001/jama.289.13.1696

I knocked softly. The room was dark as I slipped around the sage-green door, save for light sifting through the metal blinds and the blue-gray glow of the screen as it showed off its sandy sonographic images of the abdominal wall, placenta, and fetus. The obstetrician moved the slickened transducer across the woman's abdomen, pointing out landmarks and serving as guide to this anatomical museum suspended in amnion. "This is baby's kidney. And over here we have baby's stomach." Baby? Talking in the hallway out of the patient's earshot, my attending remarked, "The fetus appears on exam to be healthy." Although the proper use of "baby" vs "fetus" is generally not a part of formal obstetric training for medical students, maternal-fetal ethics instruction is a component of medical and resident education. A 1994 study found that the top 2 issues of interest in obstetric ethics education were "abortion" and "maternal-fetal conflict."1

Although obstetricians rarely encounter ethical dilemmas like court-ordered cesarean deliveries or pregnant patients refusing life-sustaining blood transfusions, unplanned pregnancy and drug and alcohol use during pregnancy are common occurrences.2,3 Thus it is not surprising that the pregnant woman is a focus of complex cultural expectations, moral obligations, and legal rights. This issue of MSJAMA addresses some of the constructs and tensions in the maternal-fetal relationship.

The maternal-fetal relationship is the subject of intense public policy debates. Lisa Harris and Lynn Paltrow report on courts' opinions regarding the prosecution of pregnant women for potential fetal harm. Nathan Stormer explores how contemporary biomedical images of the fetus are changing public perception of the pregnant body and fetus. Amy Salisbury and colleagues describe how researchers are attempting to measure maternal-fetal attachment and its possible implications for fetal and maternal health during pregnancy.

Although fundamental and seemingly unalterable, the definition of the maternal-fetal relationship is undergoing a rapid evolution of context, in part due to advances in imaging, prenatal diagnostics, genetic screening, and fetal surgery. While the formal principles of autonomy and beneficence provide an initial point from which to analyze the sometimes conflicting needs of the pregnant woman and her fetus, the maternal-fetal relationship is becoming too complex to rely on simple algorithms. As medical technology and innovation advance, and as cultural and political dialogues continue to influence the patient-physician encounter, physicians' knowledge of and participation in ethical dialogue on the maternal-fetal relationship will continue to be an increasingly important part of obstetric care.

Cain JM, Elkins T, Bernard PF. The status of ethics education in obstetrics and gynecology.  Obstet Gynecol.1994;83:15-20.
Ebrahim SH, Luman ET, Floyd RL, Murphy CC, Bennett EM, Boyle CA. Alcohol consumption by pregnant women in the United States during 1988-1995.  Obstet Gynecol.1998;92:187-192.
Henshaw SK. Unintended pregnancy in the United States.  Fam Plann Perspect.1998;30:24-29.