Pregnant adolescents are often excluded from biomedical HIV research participation, resulting in less evidence to inform safe and effective treatment and prevention strategies. We explored adolescent views on enrollment in biomedical HIV research during pregnancy via in-depth interviews with ever-pregnant adolescents living with and at-risk of HIV age 15-20 years in Botswana and Malawi. A semi-structured interview guide explored decision-making around study enrollment during pregnancy using vignettes depicting two hypothetical HIV studies: (1) testing pregnancy-specific dosage of an HIV medication, and (2) a randomized control trial comparing an oral regimen to a new injectable. Audio-recorded interviews were transcribed, translated to English, coded in NVivo, and thematically analyzed for emergent themes in participation motivators/barriers. Of the 80 adolescents interviewed (40 living with and 40 at-risk of HIV), 73 (91.3%) were interested in joining vignette study 1 and 65 (81.3%) in vignette 2. Participation motivators included treating/preventing HIV, gaining health knowledge, and helping others. Barriers included study participation requirements, the studies' experimental nature, and randomization. Adolescents' high interest in and reasons for participation during pregnancy suggest their exclusion from biomedical HIV research may be inconsistent with their views, interests, and capacities, providing important considerations for ethical and inclusive study design.

Clinical trials often require women and girls of childbearing potential to adhere to contraceptive mandates, typically requiring the use of two forms of contraceptives for the duration of the study. Understanding adolescent perspectives on contraceptive mandates within HIV prevention and treatment trials is critical for evaluating whether and when such requirements are ethically justified and, if so, how they might be appropriately applied in trials involving this group. We conducted semi-structured interviews with adolescents age 15–24 in the U.S. on their perspectives about contraceptive requirements. Interviews were audio-recorded and transcribed verbatim. We used Nvivo qualitative analysis software to code transcripts, and then conducted thematic analysis to identify emergent patterns in adolescents’ perceptions of the advantages and disadvantages of requiring contraception use for adolescent participants of HIV research studies. Forty adolescents were interviewed in total. Overall, most participants expressed support for a contraceptive requirement. Regardless of their stance, perceived advantages and disadvantages of such requirements stood in tension, including the ability to prevent pregnancy and desires to become pregnant, desirable health benefits and concerning side effects, and voluntary participation and violated decisional autonomy. Our findings illustrate that although contraceptive mandates are intended to facilitate and promote inclusion in research, they can simultaneously work to restrict adolescent participation in research and limit access to its potential benefits. In doing so, these requirements risk undermining their ethical justification and obstructing the generation of data needed to advance health outcomes for adolescents.

Leading medical organizations have called for advancement of pregnancy-specific research to reduce harmful evidence gaps. However, meeting this objective poses ethical, legal, and policy dilemmas for investigators, oversight committees, academic institutions, and sponsors. To better understand the extent to which policies may facilitate or hinder the inclusion of pregnant women in research, we conducted two studies: an international study of laws, regulations, and ethical guidelines from a diverse sample of 59 countries and a study of policies from 84 top-funded US research institutions. We found that most policies use risk-based criteria for determining whether pregnant women should be included in research. Among countries with inclusion policies for pregnant women, 76% had risk-based policies (i.e., inclusion is based on risks and benefits to the pregnant woman and/or fetus), 13% had inclusionary policies (i.e., pregnant women should or must be included in research unless there is a valid scientific or ethical reason for exclusion), and 11% had exclusionary policies (i.e., pregnant women should or must be excluded from research unless there is a valid scientific or ethical reason for inclusion). In the US study, 96% of institutions had risk-based policies, 3% had exclusionary policies, and 1% had inclusionary policies. We also found that many policies referred to pregnant women as vulnerable. To promote fair and responsible inclusion of pregnant women in research, academic institutions, sponsors, and oversight agencies should adopt and implement policies with inclusionary language and refrain from referring to pregnant women as vulnerable.

In its recent statement, the British Pharmacological Society has joined a global movement urging that pregnant and breastfeeding women should be protected not from research, but through it. Advancing this agenda marks a paradigm shift, emphasizing both the importance of the BPS endorsement and necessity of their ongoing engagement, especially to address the challenges of timely generation of evidence and the ethical complexities of early phase studies during pregnancy and breastfeeding.

Anne Drapkin Lyerly is from the Departments of Social Medicine and of Obstetrics and Gynecology at the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; [email protected]. Financial Disclosure Dr. Lyerly has received payment from UCB Biosciences and 3D Communications.

Since the U.S. Supreme Court's decision in Dobbs vs. Jackson Women's Health Organization, a growing web of state laws restricts access to abortion. Here we consider how, ethically, doctors should respond when terminating a pregnancy is clinically indicated but state law imposes restrictions on doing so. We offer a typology of cases in which the dilemma emerges and a brief sketch of the current state of legal prohibitions against providing such care. We examine the issue from the standpoints of conscience, professional ethics, and civil disobedience and conclude that it is almost always morally permissible and praiseworthy to break the law and that, in a subset of cases, it is morally obligatory to do so. We further argue that health care institutions that employ or credential physicians to provide reproductive health care have an ethical duty to provide a basic suite of practical supports for them as they work to ethically resolve the dilemmas before them.

Background: The COVID-19 pandemic resulted in an increased number of out-of-hospital births in the United States and other nations. While many studies have sought to understand the experiences of pregnant and birthing people during this time, few have compared experiences across birth locations. Objective: The purpose of this study is to compare the narratives and decision-making processes of those who gave birth in and out of hospitals during the pandemic. Design: We conducted semi-structured narrative interviews with 24 women who gave birth during the COVID-19 pandemic. Methods: Interviews were transcribed and coded, and a thematic narrative analysis was employed. Final themes and exemplary quotes were determined in discussion among the research team. Results: Results from narrative analysis revealed three themes that played into participants’ birth location decisions: (1) birth efficacy and values, (2) diverse definitions of safety, and (3) childcare and other logistics. In each of these themes, participants who gave birth in birthing centers, at the hospital, and at home describe their individualized approach to achieving a supportive birth environment while mitigating the risk of labor complications and COVID-19 infection. Conclusion: Our study suggests that for some childbearing people, the pandemic did not change birthing values or decisions but rather brought enhanced clarity to their individual needs during birth and perceived risks, benefits, and limitations of each birthing space. This study further highlights the need for improved structural support for birthing people to access a range of safe and supportive birthing environments.

Over the past 30 years, progress has been made in increasing women's representation in clinical research. However, women continue to be underrepresented in phase I clinical trials-those trials that test the safety and tolerability of investigational drugs, often on healthy individuals. As sex-based differences in adverse drug reactions are often linked to drug dose, pivotal safety information in phase I trials is often insufficiently-and inequitably-captured for females. Yet there has been little attention to how clinical investigators and those charged with overseeing the ethical conduct of these trials perceive the barriers to women's inclusion in phase I trials. To address this gap, we report on 22 interviews with U.S. phase I investigators and institutional review board (IRB) members. Our findings indicate that although these investigators and IRB members acknowledged the importance of including women in clinical trials, they justified women's exclusion from phase I trials by citing the need to manage their reproductive potential. In particular, we identified four key themes that informants used to warrant women's exclusion from phase I trials: the structure of the drug-development system itself, fears about risks to potential fetuses, distrust of women to prevent pregnancy, and concerns about risks and burdens to institutions from resulting pregnancies. We argue that these rationales reflect structural and cultural barriers to women's inclusion in clinical research that ultimately fail to respect female research participants as persons, highlighting the need for broad-based solutions.

Following the 2022 US Supreme Court decision in Dobbs vs. Jackson Women's Health Organization, numerous states have passed laws banning or severely restricting abortion. The consequences of the decision stretch beyond abortion contexts, including progress on developing a more robust evidence base for care in pregnancy. In this Robert L. Brent lecture, I explore the impact of the Dobbs decision on teratology research, arguing that it is of importance even and perhaps especially for those concerned about the moral complexities of ending a pregnancy. For as abortion restrictions threaten teratology research, they also threaten its life-affirming aims. First, I show how teratology research and abortion are intertwined, highlighting the stories of Sherri Finkbine and Frances Kelsey, two courageous women whose lives intersected with both. Second, I describe how restrictions on abortion make teratology research more difficult and ethically complex, highlighting additional risks to research participants and staff, as well as new challenges to scientific validity and feasibility. And third, foregrounding yet another story of courage (and heartbreak), I highlight how abortion restrictions make teratology research more important than ever. Honoring Dr. Brent's legacy requires addressing-rather than avoiding-the ethical challenges of pregnancy-related research, especially now in the post-Dobbs era.

PurposeTo describe psychological outcomes among people with recurrent anomalous pregnancies pursuing trio-exome sequencing (exome sequencing (ES)) compared to those with one affected. MethodsWe analyzed data from a prospective ES cohort, enrolling patients with major fetal anomaly and normal microarray. Participants completed validated scales before and after ES. We (1) compared responses of those with multiple anomalous pregnancies to those with one affected and (2) conducted linear regression to examine associations between multiple affected pregnancies and post-ES constructs. ResultsOf 166 trios, 61 (37%) received results from ES. Forty (24%) had more than one affected pregnancy and 45% of those received a result explaining the fetal phenotype. All participants had clinically significant presequencing generalized psychological distress. For the 93 who completed the post-ES surveys, those with multiple affected pregnancies had higher psychological adaptation scores but worse test related distress scores (9.3 (6.2) versus 7.1(5.6), p = 0.12) and (14.3 (1.5) versus 15.4 (1.4), p = 0.01). In linear regression models, there were no significant differences in post-ES constructs after adjusting for clinically relevant covariates. ConclusionsAll individuals experienced significant generalized psychological distress in the pre-ES period, extending our knowledge of how pregnancy history contributes to parental sequencing outcomes.

OBJECTIVE: On November 22, 2022, 2 hospitals in Oregon declared crisis standards of care (CSC) in response to the “tripledemic,” or rising rates of influenza, respiratory syncytial virus, and COVID-19.1Oregon Health & Science University. Communications. OHSU Doernbecher Children's Hospital implements crisis standard of care. 2022. Available at:https://news.ohsu.edu/2022/11/22/ohsu-doernbecher-childrens-hospital-implements-crisis-standards-of-care. Accessed December 8, 2022.Google Scholar CSC guidelines direct the triage of limited resources when demands for healthcare exceed standard capacity, such as intensive care unit beds. Hospital CSCs are adopted from statewide CSCs,2Truog RD Mitchell C Daley GQ. The toughest triage – allocating ventilators in a pandemic.N Engl J Med. 2020; 382: 1973-1975Crossref PubMed Scopus (478) Google Scholar and many states developed their CSC policies during the COVID-19 pandemic, which placed a global strain on the healthcare infrastructure. A systematic review of allocation guidelines found that the Sequential Organ Failure Assessment (SOFA) score is used to determine priority for allocation of scarce resources among patients seeking the same resource.3Piscitello GM Kapania EM Miller WD Rojas JC Siegler M Parker WF. Variation in ventilator allocation guidelines by US state during the coronavirus disease 2019 pandemic: a systematic review.JAMA Netw Open. 2020; 3e2012606Crossref PubMed Scopus (75) Google Scholar However, the SOFA score has not been validated in pregnancy when normal physiological changes, such as platelet count and bilirubin level, are expected to affect score parameters compared with nongravid physiology.4Fadiloglu E Bulut Yuksel NDB Unal C et al.Characteristics of obstetric admissions to intensive care unit: Apache II, SOFA and the Glasgow Coma Scale.J Perinat Med. 2019; 47: 947-957Crossref PubMed Scopus (3) Google Scholar In this report, we assess whether statewide CSC guidelines active during COVID-19, included pregnancy. Among those that do, we describe the ethical triage principles used in allocation guidelines when a pregnant patient was among potential recipients. STUDY DESIGN: We conducted a retrospective review of publicly available and state-level CSC guidelines, obtained through online search and communication with ethics consultants from state governments. CSC guidelines were systematically and independently reviewed by 2 authors for content including ethical framework, resource prioritization strategies, and any accommodations for pregnancy. We specifically searched for terms including “pregnancy,” “perinatal,” “gravid,” and “maternal.” Among the included CSCs that mentioned the aforementioned terms, we read the accommodation and abstracted the text for review and classification. Reviewer discrepancies were adjudicated by discussion. Descriptive statistics were used to summarize CSC characteristics. RESULTS: A US state-level CSC was identified for 41 of 50 (82%) states (Figure). Among these, 34 CSCs (82.9%) had a specific strategy for prioritizing patients for critical care resources, all of which incorporated the SOFA score. When SOFA score was used, 13 (13/34; 38.2%) allocation strategies mentioned pregnancy (Table). Of the 13, 7 (53.8%) acknowledged pregnancy as a special circumstance requiring individualized decision-making, 3 (23.1%) reduced SOFA priority score by 2 points, 2 (15.4%) used pregnancy as a tiebreaker, and 1 (7.7%) created a separate tier system for pregnant patients. Of the state CSCs including pregnancy, the median (quartile 1–quartile 3) year published was 2020 (2017–2020), the same if pregnancy was not included (2020 [2017–2020]).TablePregnancy-specific accommodations within the 13 states mentioning pregnancyGatta. Pregnancy inclusion in crisis care guidelines. Am J Obstet Gynecol MFM 2023.StateModificationSpecific languageAZPregnancy as a special consideration“If two or more patients require a single resource, additional factors may be considered as priorities, including…pregnancy” (Published June 2020)COPregnancy as a special consideration“Pregnancy – priority for a scarce resource may be given to a patient with a confirmed pregnancy over a non-pregnant patient” (Published January 2020)IDPregnancy as a tiebreaker“Several “tiebreakers” should be used…Priority should next go to pregnant women with a viable pregnancy ≥ 28 weeks of gestation” (Published September 2020)MDPregnancy as a special circumstance“The scoring system cannot take into account the complex moral and medical considerations [pregnancy] poses.” (Published September 2017)MATwo-point reduction in priority score“If a pregnant patient is at or beyond the usual standards for fetal viability, the patient will be given a two-point reduction in priority score, giving the person a higher priority score.” (Published April 2017)NETwo-point reduction in priority scoreSame as MA (above) (Published May 2021)NHPregnancy as a tiebreaker“In the event of a tie between a pregnant woman and another non-pregnant patient…fetal viability should be performed. If normal, priority should be given to the pregnant woman” (Published June 2022)NYPregnancy as a special circumstance“Plans for health care would be made in advance at a regional perinatal center that could accommodate the special needs of both pregnant women and neonates.” (Published November 2015)NCPregnancy as a special circumstance“Assessment tools, such as the SOFA/mSOFA, or the priority scoring process may need reasonable modifications with respect to disabilities, pregnancy, or pre-existing condition.” (Published January 2021)ORPregnancy as a special circumstance“When the capacity exists to assess the unborn child's status, and, based on that assessment and available resources, there is a high likelihood of the infant's survival, [pregnancy] could be considered in resource allocation decisions.” (Published June 2018)PATwo-point reduction in priority scoreSame as MA (above) (Published April 2020)RIPregnancy as a separate tier“The score for prognosis for short-term survival [in a pregnant patient] will…be determined by the predicted likelihood of short-term survival, based on the assessment of the triage officer in consultation with the obstetrical medicine attending and the Maternal and Fetal Medicine (MFM) attending. Patients with predicted survival of 76%-100% will be assigned as Level 1; those with predicted survival of 26%-75 % will be assigned as Level 2, and those with predicted survival of 0%-25% will be assigned as Level 3.” (Published April 2020)UTPregnancy as a special circumstancePatients with pregnancy may represent two lives, and thus giving them priority isaligned with “do the greatest good for the greatest number.” (Published November 2020)AZ, Arizona; CO, Colorado; ID, Idaho; MA, Massachusetts; MD, Maryland; NC, North Carolina; NE, Nebraska; NH, New Hampshire; NY, New York; OR, Oregon; PA, Pennsylvania; RI, Rhode Island; SOFA, sequential organ failure assessment; UT, Utah. Open table in a new tab AZ, Arizona; CO, Colorado; ID, Idaho; MA, Massachusetts; MD, Maryland; NC, North Carolina; NE, Nebraska; NH, New Hampshire; NY, New York; OR, Oregon; PA, Pennsylvania; RI, Rhode Island; SOFA, sequential organ failure assessment; UT, Utah. CONCLUSION:Most US states do not consider pregnancy in their CSC guidelines for scarce resource allocation. Among the CSCs that do, there was wide variability in their strategies to include pregnancy as a criterion, which fell into 4 categories: reducing the SOFA score by 2 points, using pregnancy as a tiebreaker, calling for individualized decision-making among triage officers, and creating a separate allocation system. By default, when triaging a scarce resource among patients, a critically-ill pregnant patient would be evaluated by a mortality prediction model that excluded pregnancy during its development. Because the SOFA score is not predictive of mortality in pregnancy, failure to consider pregnancy as a separate criterion for triaging may result in inappropriate deprioritization. The net effect may be to artificially skew a scarce resource away from pregnant patients, raising concerns about ethical allocation of resources. As a population with a comparatively low mortality rate when critical resources are used,5Metz TD Clifton RG Hughes BL et al.Disease severity and perinatal outcomes of pregnant patients with coronavirus disease 2019 (COVID-19).Obstet Gynecol. 2021; 137: 571-580Crossref PubMed Scopus (191) Google Scholar pregnant patients stand to benefit from critical care resources. Harms of deprioritization are further compounded by the fact that intervention during pregnancy has the potential to save 2 (or more) lives. Utilitarian arguments aside, each critically ill patient deserves fair access to scarce resources, and pregnant physiology at baseline should not limit access to a life-saving intervention. Our findings suggest that current models implemented in CSCs may systematically disadvantage pregnant patients. Until predictive modeling more accurately incorporates the unique physiology of pregnancy, the SOFA score should not be used by default. In the interim, acknowledging pregnancy as a special circumstance, as 7 states have (Table), alongside individualized decision-making in conjunction with maternal-fetal medicine subspecialists, may serve as a model to be adopted within CSCs. The study limitations include that we did not assess CSCs that were in development or under review. Furthermore, we did not assess hospital or health-system level CSCs, which may be implemented before a state-level CSC is deployed, as was the most recent case in Oregon.1Oregon Health & Science University. Communications. OHSU Doernbecher Children's Hospital implements crisis standard of care. 2022. Available at:https://news.ohsu.edu/2022/11/22/ohsu-doernbecher-childrens-hospital-implements-crisis-standards-of-care. Accessed December 8, 2022.Google Scholar However, because CSCs at the hospital level often model their guidelines off the state CSC, assessing state-level CSCs may be an appropriate proxy to understand how pregnancy is included in the allocation of scarce resources. Most US state-level CSCs do not consider pregnancy in resource allocation strategies. Among those that do, there is wide variability in its inclusion. The authors would like to thank William F. Parker, MD, faculty at the MacLean Center at the University of Chicago, for his valuable contributions to this report.

Pregnant individuals often face medical illness, ranging from diabetes to cancer to infectious disease to mental health disorders. Yet—in large part due to ethical concerns about imposing unknown risk on the fetus in research settings—the evidence base to inform their care is sorely lacking.1 For example, although coronavirus (COVID-19) infection poses higher risks in pregnancy, pregnant individuals were excluded from trials leading to the approval of therapies such as the antiviral remdesivir.2 Though data are slowly accumulating from case reports of clinical and compassionate use, significant evidence gaps remain—notably among them, a near absence of data describing the pharmacokinetics of such therapies in pregnancy.3 Recently, the US Food and Drug Administration (FDA) has joined a chorus of leading voices calling for pregnancy-specific research, characterizing efforts to fill knowledge gaps a “critical public health need.”4 Of perhaps most prominent public concern are extensive gaps regarding drug safety for the fetus. More than 95% of drugs approved between 2000 and 2010 lack sufficient evidence to determine teratogenic risk5; questions about longer-term impacts on children, such as neurocognitive status, remain unanswered.6 Without sufficient data, pregnant individuals may be prescribed drugs that could potentially harm the fetus, feel guilt about adverse outcomes unrelated to use,7 or, most impactfully, lack access to (or be disinclined to use) medications necessary to treat maternal disease.8 Yet equally important, if less well recognized, are extensive gaps regarding the pharmacokinetics of drugs in pregnancy, inspiring the FDA’s public workshop on the topic in May 2022. The absence of pharmacokinetic (PK) data on COVID-19 therapeutics reflects a trend across diseases, for which a paucity of clinically actionable PK data in pregnancy exists.9 Even for HIV, where research to prevent vertical transmission has been a priority for decades, most drugs come to market without pregnancy-specific PK data. Delays in gathering such data are long, averaging 6 years for the most commonly used antiretrovirals; for many others, these data are never gathered.10 Despite the recognized need, research in pregnancy in general presents additional challenges above and beyond research in nonpregnant populations. Barriers include misaligned incentives within drug development pathways, limits on regulatory authority to require needed studies, and specific patterns of reasoning around pregnancy and research that disincline researchers to conduct studies and institutional review boards to approve them.11 Major shifts in how we think about pregnant individuals (not vulnerable but complex), how to protect them (not from research but through it), and what justice requires (fair inclusion in biomedical research) are needed and beginning to take hold.12 Looking forward, PK research in pregnancy offers immediate, near-term opportunities to improve the evidence base; it is, in many ways, an ethical “lowhanging fruit.” First, PK research offers a particularly strong case for the position that research in pregnancy is ethically imperative. A central purpose of biomedical research—indeed, a core responsibility of the FDA13—is to protect the public from harms of unsafe and ineffective drugs through rigorous studies in highly controlled contexts.11 Like other populations,

Introduction: The COVID-19 pandemic led to unprecedented changes in care delivery across the pregnancy care con-tinuum. Our primary objective with this research was to characterize the range of ways that the early months of the COVID-19 pandemic affected pregnancy, childbirth, and postpartum care experiences. Methods: Pregnant and recently pregnant patients (n 1/4 20) from obstetrics and gynecology clinical sites associated with Massachusetts General Hospital were interviewed about their experiences with prenatal care, childbirth, and post-partum care during the first wave of the COVID-19 pandemic. Interview transcripts were analyzed for emergent themes. Results: This sample included 20 pregnant and postpartum people, including 11 individuals who tested positive for COVID-19 during pregnancy or postpartum and nine with suspected infection. The ways in which COVID-19 or sus-pected COVID-19 affected experiences of prenatal care, childbirth, and postpartum care were complex and varied. Three themes were identified across narratives of pregnancy, birth, and postpartum care: patient perceptions of diminished access to care, stigma due to COVID-19 infection, and limited capacity of providers to honor patient preferences. Conclusions: A better understanding of pregnant and recently pregnant people's experiences during the early months of the COVID-19 pandemic can inform infection control policies and clinical care delivery practices that are more congruent with the needs and values of pregnant, birthing, and postpartum people as institutions craft responses to future pandemics. Approaches that maximize meaningful access across the pregnancy care continuum, center patients' priorities within adapted care models, and honor patient preferences as much as possible are important aspects of an appropriate response to future waves of COVID-19 and other pandemics.& COPY; 2022 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights reserved.

PURPOSE:To understand motivations for and parental interpretation of results from trio-exome sequencing (ES) for fetal anomalies with a negative standard genetic diagnosis.METHODS:Analysis of an ongoing, prospective prenatal trio-ES study of pregnancies with ultrasound-identified congenital anomalies and lack of a standard genetic diagnosis. After determination of pregnancy disposition, participants completed questionnaires and a semi-structured interview pre- and post-sequencing. Interviews were analyzed using a constructivist grounded theory methodology to identify themes. Associations between themes and ES result were also examined.RESULTS:One hundred twenty-six trios have been sequenced. Of those, 45 (36%) resulted in fetal diagnosis. One hundred twenty-five women completed pre-sequencing surveys, and 91 women completed post-sequencing surveys. The main themes identified include (1) variable reasons to pursue ES, (2) limited expectations but high hopes from ES, (3) parental adaptation to uncertain results, (4) impact on personal health and reproduction, and (5) gratitude for the process.CONCLUSION:Participants pursued ES for various reasons, most often to identify a diagnosis and guide reproduction. Post-sequencing, most participants described the process, their interpretation of results, and the impact of receiving the results. Less frequently, but of most concern, participants expressed anxiety about testing and implications for themselves, relationships, and other family members, thus identifying an area of high need for additional support among patients undergoing prenatal ES.

Safekeeping involves transferring individuals from jails to prisons without the presence of a conviction. In North Carolina, safekeeping is used for pregnant people with the aim of providing better prenatal care. We interviewed 14 stakeholders in the safekeeping process including sheriffs, clinicians, advocates, and lawyers. Three key themes emerged: jails' inability to provide care for pregnant individuals; safekeeping as an additional punishment to incarceration; and differing attitudes on the necessity of safekeeping. Participants perceived that while there may be some benefits of safekeeping such as enhanced prenatal care, safekeeping can also lead to worsened conditions for pregnant people experiencing incarceration.