frequency of survival has ranged from 26–76% among neonates born at 23 weeks of gestation, whereas those born at 24 weeks of gestation have a reported survival rate of 55–87%. The majority of survivors born at the periviable stage will incur major morbidities, regardless of gestational age at birth. Although survival is less frequent at 23 than at 24 weeks of gestation, 23 weeks of gestation is not an inflection point for futility. The suggestion that the survival and intact survival rates at 23 weeks of gestation are insufficient to warrant intervention, but that outcomes at 24 weeks of gestation are sufficient, is an opinion that has been held in the past for neonates born at 24–26 weeks of gestation. Where data exist, we encourage counseling based on available information rather than opinion. Where data are lacking, we stress the importance of an objective review of available information in a manner preferred by the family. We encourage close, perhaps repeated interactions with the family while making the difficult decisions regarding treatment issues. We strongly believe that such counseling should not be biased by the preconceived opinions of caregivers. Financial Disclosure: The authors did not report any potential conflicts of interest. The opinions expressed here do not necessarily reflect those of the National Institutes of Health, Department of Health and Human Services, or that of the United States Federal Government, or those of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, or American Academy of Pediatrics. Gerald R. Joseph Jr is an employee of the American College of Obstetricians and Gynecologists (the College). All opinions expressed in this article are the authors’ and do not necessarily reflect the policies and views of the College. Any remuneration that the authors receive from the College is unrelated to the content of this article.

Brian M. Mercer, MD Society for Maternal-Fetal Medicine and Case Western Reserve University– MetroHealth Medical Center, Cleveland, Ohio Tonse N.K. Raju, MD Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland David J. Burchfield, MD American Academy of Pediatrics and University of Florida, Gainesville, Florida

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Letters to the Editor

Gerald F. Joseph, Jr, MD American College of Obstetricians and Gynecologists, Washington DC

REFERENCE 1. Raju TN, Mercer BM, Burchfield DJ, Joseph GF Jr. Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal Fetal Medicine, American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:1083–96.

Adding Injury to Injury: Ethical Implications of the Medicaid Sterilization Consent Regulations To the Editor: I completely agree that the current waiting period regulations for sterilization are unethical and do more harm than good,1 and I have not met an obstetrician–gynecologist or midwife who believes otherwise. As regulations, not laws, they can be changed after a period of public commentary and review by the Department of Health and Human Services. The burning question is how to start the process. Since 2011, I have written four times to Department of Health and Human Services, twice with supporting letters from members of the Massachusetts Congressional Delegation, requesting action. Most recently, in 2014, I also included a supporting letter from District I of the American College of Obstetricians and Gynecologists, which additionally referenced the recently reaffirmed concurring opinion of the American Medical Association.2 The Department of Health and Human Services responded only once, in December 2011, when the Deputy Assistant Secretary for Population Affairs replied that these “concerns are valid, and will be taken into consideration when the regulations are next reviewed within HHS.” I inquired when that would be (no response), and now, going on 3 years later, there is still no review process scheduled. Do the authors have ideas or plans to elicit action from the Department of Health and Human Services? Equal

access to sterilization should be a priority in reproductive health care. Financial Disclosure: The author did not report any potential conflicts of interest.

Sylvia Fine, MD Cambridge, Massachusetts

REFERENCE 1. Brown BP, Chor J. Adding injury to injury: ethical implications of the Medicaid sterilization consent regulations. Obstet Gynecol 2014;123:1348–51. 2. http://www.ama-assn.org/resources/doc/ img/i13-summary-of-actions.pdf. Retrieved July 17, 2014.

In Reply: We agree with Dr. Fine that physician advocacy is an excellent first step toward addressing this barrier to care. Unfortunately, as her experience illustrates, individual doctors often hold little sway with large bureaucracies— even when they are backed by legislators or local professional societies. A coordinated advocacy effort by the American College of Obstetricians and Gynecologists (the College), at the regional and national level, supported by other national organizations likely will be necessary to effect change in these rules. We would like to see federal sterilization regulations become a higher lobbying priority for the College. Specifically, the College should call for revised consent guidelines that apply to all women (not just to those who are federally insured) and that do away with the 30-day waiting period and the proscription on obtaining consent in labor while providing safeguards to ensure that no woman is coerced into undergoing a tubal ligation. Financial Disclosure: The authors did not report any potential conflicts of interest.

Benjamin P. Brown, MD Department of Obstetrics and Gynecology, University of Chicago Medical Center, Chicago, Illinois Julie Chor, MD, MPH Department of Obstetrics and Gynecology, University of Chicago Medical Center and, MacLean Center for Clinical Medical Ethics, Chicago, Illinois

OBSTETRICS & GYNECOLOGY