Infection Prevention and Control in Residential Facilities for Pediatric Patients and Their Families

Judith A. Guzman-Cottrill, DO; Karen A. Ravin, MD; Kristina A. Bryant, MD; Danielle M. Zerr, MD; Larry Kociolek, MD; Jane D. Siegel, MD


Infect Control Hosp Epidemiol. 2013;34(10):1003-1041. 

In This Article

Core Principles of Infection Prevention and Control


Preventing transmission of infectious agents among patients, families, and healthcare personnel is a challenge in all settings where health care is delivered. There is considerable research informing the recommendations made for preventing transmission of infectious agents in healthcare facilities in guidelines and position papers published by the Healthcare Infection Control Practices Advisory Committee/Centers for Disease Control and Prevention (HICPAC/CDC),[9] SHEA,[10] and the Infectious Diseases Society of America (IDSA).[10] There has been little research and few published guidelines for ambulatory settings. Similarly, infection transmission within family-centered facilities has not been evaluated. Special ambulatory settings for which infection prevention and control guidelines do exist include hemodialysis centers[11] and CF clinics.[12] In 2011, guidelines for general outpatient clinics[13] and oncology clinics[14] were developed by the CDC that describe the minimum expectations for safe care in outpatient settings. There is no research to inform recommendations to prevent transmission of infectious agents in family-centered facilities that serve as a "home away from home."

Although RMHs are not healthcare facilities, they are "residences" with potential for exposure to infectious diseases. Patients with medical conditions that make them particularly vulnerable to infection live in and share common facilities with many other children and their families. Such communal living can provide opportunities for transmission of infectious agents if caution is not taken. By understanding the principles of prevention of infection transmission, all individuals who live and work in such facilities can reduce the risk of infection for children and families whom they serve.

Standard Precautions

Standard Precautions are a set of practices aimed at preventing transmission of infectious agents and are based on the principle that all blood, body fluids (eg, material coughed up and saliva), secretions, excretions (eg, urine, stool, and wound drainage but not sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. Therefore, containing these fluids will reduce the risk of transmission of infectious agents. Employees, volunteers, patients, family members, and visitors must all partner in preventing transmission of infections in healthcare settings. Recommendations for Standard Precautions are based on strong evidence from healthcare settings that has been summarized and referenced in several guidelines published by HICPAC/CDC,[9] the IDSA,[15] and the World Health Organization.[16]

Elements of Standard Precautions that can be applied in RMHs or similar facilities are as follows:

  1. Hand hygiene : This is a general term that applies to any one of the following: (a) hand washing with plain (non-antimicrobial-containing) soap and water, (b) hand washing with soap containing an antiseptic agent, or (c) cleaning hands with a waterless alcohol-based hand rub containing at least 60% alcohol. Performing hand hygiene at the appropriate times is a critical step one can take to prevent transmission of infectious agents and has been shown to be effective in both healthcare and nonhealthcare settings, such as day care centers, dormitories, and schools.[17–20] Placement of alcohol-based hand rub dispensers at the entrance to facilities; in hallways; in guest rooms; in areas where food is prepared, served, and consumed; and in areas where there may be contact with house pets will facilitate performance of hand hygiene by all guests and visitors. Hand washing with soap and water is preferred after handling soiled diapers or items contaminated with stool and whenever hands are visibly soiled.

  2. Glove use : Gloves should be used to provide additional protection when individuals are likely to come in contact with body secretions, excretions, nonintact skin, and mucous membranes. It is important to understand that gloves are not a replacement for hand hygiene. Gloves reduce the level of contamination on hands but they do not eliminate it because there may be tiny holes that are not visually obvious. Furthermore, hand hygiene is recommended after removing gloves since hands can become contaminated in the process of removing gloves. Also, gloves are meant to be used only a single time and should never be washed and reused because infectious agents cannot be washed off of gloves. In healthcare settings, hands are cleaned both before and after glove use. In a home setting this is ideal, but washing hands immediately after glove removal is a must.

  3. Respiratory hygiene/cough etiquette : Since it is not always known what respiratory agent a person may have when there are signs of respiratory illness, including cough, congestion, rhinorrhea (runny nose), sneezing, or increased production of respiratory secretions, all respiratory secretions are considered potentially infectious. Therefore, it is recommended to cover the mouth and nose with a tissue when coughing or sneezing, immediately dispose of the tissue in a waste receptacle, and perform hand hygiene when finished. If tissues are not readily available, then sneezing or coughing into one's sleeve is safer than sneezing or coughing into the air. However, caution is advised if it is likely that an infant or child will be cradled or held in one's arms and come into contact with soiled sleeves. Since most viruses and bacteria travel a distance of 3–6 feet (1–2 meters), it is advised that vulnerable patients remain at least 3–6 feet (1–2 meters) away from individuals who are coughing or sneezing. Medical care providers will advise patients with weakened immune systems to avoid crowded places and/or to wear masks when they are in public areas for additional protection against respiratory tract infections. These "surgical masks," sometimes referred to as "isolation masks," cover the mouth and nose but do not fit tightly on the face. If someone is coughing near a vulnerable child, move the child away from that person or ask the coughing person to move away from the child and/or to please cover his or her cough for the protection of others. See Appendix B ("Vaccines") for additional steps that can be taken to reduce the risk of acquiring certain vaccine-preventable respiratory tract infections.

  4. Blood and body fluid precautions : Some infectious agents can be acquired from exposure to blood and body fluids. Staff, volunteers, and guests should always assume that any blood or body fluid may be infectious.

    1. Advise families to not share personal items such as toothbrushes or razors with others, even within their own family.

    2. Restrict entrance of an individual with open skin lesions that cannot be covered or other conditions that might allow contact with their body fluids.

    3. If an infected person or their family member has behaviors (eg, biting) that might put others at risk of contact with their blood or body fluids, specific restrictions may be required and should be determined on an individual basis.

    4. See section 7 ("Cleaning and disinfection of environmental surfaces") below for guidance on cleaning surfaces contaminated with blood.

  5. Safe injection practices : Caregivers may need to use needles to administer medications either through a central venous catheter (often called a central line or PICC line) or by direct injection (eg, insulin). Because needles are contaminated with a patient's blood after injection, it is possible for a caregiver or program staff member to acquire a bloodborne infection if he/she sustains an accidental needlestick with a used needle. Hepatitis B and C viruses and human immunodeficiency virus (HIV) can be transmitted via needlestick injuries. Hospital personnel should instruct families how to safely handle needles at the time when methods of injectable medication administration are taught. All needles used for medication administration must be handled carefully. Used needles and syringes must never be recapped or used more than once. Single-dose vials of medications are always preferred over multidose medication vials to reduce the risk of contamination. Medication vials, insulin pens, and fingerstick devices for blood sugar monitoring must be used for only a single person. These medical supplies and devices should be stored in the guest's private room at all times. Needles must be disposed of separately from all other trash in a rigid, puncture-resistant container. Housekeeping staff and volunteers should exercise caution when cleaning linens and clearing rooms in the event that needles have not been disposed of appropriately. Additional information about safe injection practices may be found on the CDC website (

  6. Laundry : Linens or clothing that become soiled with blood, stool, or vomitus should be removed as soon as possible in a manner that prevents transfer of infectious agents to others or to the environment. In addition, the following recommendations will further prevent the spread of infectious agents from contaminated linens and clothing:

    1. Do not shake soiled linens or clothing.

    2. Soiled linens and clothing should be placed in a plastic bag to completely contain fluids.

    3. Keep soiled linens and clothing separate from other laundry. Wash soiled linens or clothing in hot water with detergent as soon as possible.

  7. Cleaning and disinfection of environmental surfaces : Microorganisms can be spread by contact with an infected person (direct spread) or by touching an object or a surface contaminated with infectious secretions or body fluids (indirect spread).[9] Many bacteria and viruses can survive for prolonged periods of time on environmental surfaces.[21] For example, influenza virus can survive on hard surfaces such as stainless steel and plastic for 24–48 hours.[22] Cleaning and disinfecting objects and surfaces can help prevent the spread of infection in family-centered residential facilities. Cleaning involves removal of dirt and surface contamination, usually by scrubbing with a detergent and then rinsing with water. Disinfection destroys or inactivates most pathogens (with the exception of spores) on objects or surfaces and is especially important for food preparation surfaces. Since the action of disinfectants is reduced if visible substances (eg, stool and nasal discharge) are not removed first, cleaning is an especially important first step.

    1. Follow routine housekeeping procedures (eg, cleaning, wet mopping, dusting, and vacuuming) that are recommended to reduce the spread of infection in facilities such as child care centers and schools. The American Academy of Pediatrics (AAP) offers a reference guide that includes recommendations for routine environmental cleaning and disinfection in these settings.[23]

    2. All facilities should have a procedure in place for routine cleaning and disinfection of environmental surfaces in common areas that specifies the following:

      1. Who is responsible for cleaning and disinfection.

      2. What areas and items are to be cleaned and/or disinfected.

      3. Frequency of cleaning and disinfection.

      4. Who is responsible for supervising and inspecting procedure.

      5. Frequency of inspections.

      6. Documentation of procedure completion and compliance.

    3. For areas that require disinfection (eg, toilet and diapering areas and food preparation areas), use products registered with the US Environmental Protection Agency as detergent-disinfectants or hospital-grade germicides. A solution containing 1/4 of a cup (approximately 59.1 mL) of household bleach in 1 gallon (3.8 liters) of tap water is also appropriate for disinfection unless surfaces are contaminated with blood or other potentially infectious body fluids.

    4. Immediately clean spills of blood and other potentially infectious body fluids using disposable towels, wearing disposable gloves. Dispose of blood-contaminated materials in a plastic bag that can be closed with a secure tie. A more concentrated solution of 1 part bleach to 9 parts water should be used to disinfect surfaces contaminated with blood and other body fluids.

    5. For floors, rugs, and carpeting contaminated by body fluids: while wearing gloves, immediately blot to remove excess fluid, then spot clean the area with a detergent-disinfectant. Shampooing or steam cleaning may be required.

    6. In common areas and playrooms, choose toys that can be easily cleaned and disinfected (avoid stuffed or cloth toys because they are not easily cleaned). Clean and disinfect toys daily or more frequently when toys are contaminated with oral or nasal secretions. Small plastic toys may be cleaned and disinfected in a mechanical dishwasher as long as dishes are not washed at the same time. To reduce the potential for environmental contamination with fecal matter, instruct families to perform diaper changes in a guest's room or the bathroom (or other clearly designated area). Diaper changes should not take place in common areas.

    7. Place soiled diapers in lidded, plastic-lined designated receptacles remote from food preparation areas. Regularly clean and disinfect diaper-changing tables in communal bathrooms (at minimum once daily or whenever visibly soiled).

    8. Never use sinks intended for hand washing or food preparation for rinsing soiled clothing or linens, for cleaning equipment that is used in toileting, or for disposal of cleaning waste water.


Animals can be a source of various organisms that cause infections in humans. Thus, family-centered residential facilities should ensure that animals allowed facility entry are healthy. Facilities should be aware of local and federal laws related to service animals. To minimize the risk of animal-related infections, recommended precautions include the following:

  1. Do not allow reptiles or rodents (including mice, hamsters, gerbils, and rats).

  2. Fish tanks are acceptable as long as they are appropriately maintained and covered, to prevent aerosolization of water into the surrounding air and to prevent guests from placing their hands in the tanks.

  3. Do not allow guests to play with fish tank water.

  4. Ensure that service or pet animals are healthy prior to facility entry by requiring written documentation.

  5. If service or pet animals are present, perform hand hygiene both before and after touching the animal.

  6. Do not allow service and pet animals to lick guests with invasive devices or compromised immune systems.

  7. Do not allows guests to handle animal feces or excrement.

  8. Notify immune-compromised guests if an animal is present in the house. Request the family to consult the patient's healthcare provider to determine if animal avoidance is recommended.

Protection of Highly Immune-compromised Patients From Exposure to Mold Spores

Organisms routinely found in soil, water, construction dust, and decaying organic matter, including fungal organisms such as Aspergillus species that release spores into the air, may cause serious disease of the lungs, sinuses, brain, and other organs in highly immune-compromised patients (eg, those with very low white blood cell counts and stem cell transplant recipients). In hospitals, hematopoietic stem cell (bone marrow) transplant patients are the most immune-compromised patients and are housed in units with specially filtered air handling systems, increased number of air exchanges per hour, and rooms with specialized air flow with respect to other rooms and corridors, called a Protective Environment. Once these patients are well enough to no longer require this protective environment, they may be discharged from the hospital to home or to a family-centered residential facility. Such facilities are not medical facilities and, thus, are not equipped to provide a Protective Environment for these patients. However, simple measures that might be undertaken in a home to reduce the risk of airborne transmission of fungal organisms could be implemented in these facilities. These include proper installation and maintenance of heating, ventilation, and air conditioning (HVAC) systems and scheduled changes of filters according to manufacturers' recommendations, to prevent dust overload. When activities that increase dispersal of fungal spores from the soil are anticipated, including construction and renovation projects, medical personnel at the affiliated facility should be notified, and guests should be informed. During construction and renovation, highly immune-compromised individuals should consult their healthcare providers about their exposure risks and inquire if alternative housing should be considered.

Additional precautions that could be recommended by the highly immune-compromised child's healthcare team are listed below:

  1. Avoid exposure to construction sites or the outdoors on windy days.

  2. Wear a special type of mask (N95 respirator) that fits tightly on the face when going outdoors for necessary travel to and from the hospital.

  3. Avoid carpeting, because carpet can retain mold spores that may be dispersed into the air during vacuuming or other activities.

  4. If carpeting is present, vacuum the area regularly using a high-efficiency particulate air (HEPA)–filtered vacuum when the patient is not present.

  5. Avoid the use of humidifiers and dehumidifiers in common areas. If humidifiers or dehumidifiers are used in individual rooms, observe the recommended care practices per manufacturer or as instructed by healthcare staff members.

  6. Do not keep potted plants or fresh flowers in the room.

  7. Avoid gardening, digging, and spreading mulch or soil.

  8. Avoid areas where gardening, digging, and mulching are taking place.

Health Screening of House Guests and Visitors

All visitors and prospective guests should be systematically screened for illness or exposure to infectious diseases when they arrive at the reception desk or when arrangements for admission are being made. The process should include a standardized list of symptom and exposure questions; a health screening tool is provided (Appendix A) and can be modified to fit the needs of each family-centered facility. Each facility should develop a standardized method to ensure that all staff members are trained to follow the same procedure. If a visitor answers yes to any of the questions, the visit should be rescheduled for a future date. Similarly, prospective guests who answer yes to any of the questions should arrange for alternative accommodations or should remain in their private room, depending on the specific situation (see "Specific Diseases and Pathogens" for additional guidance). Since hospital social workers are frequently involved in the family screening and referral process, it is important for them to be aware of the screening process details.

Each prospective guest should be asked about his or her varicella (chickenpox) immune status, and this information should be maintained on file until the guest checks out from the facility, always being aware of and taking steps to maintain the confidentiality of this information. Rapid access to this information is beneficial in the event that a facility is involved in a varicella outbreak investigation. Throughout the influenza season (from September to March in the Northern Hemisphere), prospective guests should be asked about their influenza vaccination status. If the family member has not yet received an influenza vaccine, program staff should provide information about the importance of immunization, especially while living in a community setting. Whenever possible, family-centered facilities may assist guests with identifying local facilities that offer influenza vaccines (eg, pharmacies and health department clinics).

Family members of a patient who is diagnosed with an infectious disease should not be automatically excluded from services. Program staff members should refer to "Specific Diseases and Pathogens" for details. Some specific illnesses of epidemiologic significance require a signed medical clearance document, confirming that the family members are not an infectious risk to guests, staff, and volunteers. The document should be completed by a healthcare provider who is familiar with the child's medical condition. Each organization operating a family-centered residential facility should use a standardized document so that all staff can easily identify a properly completed form; a sample medical clearance form is provided (Appendix A) and can be modified to fit the needs of each program. If the family is unable to obtain a signed medical clearance form or if the form is incomplete, then the family should not be referred or allowed entry to the facility.

If a situation arises where these guidelines do not provide a clear recommendation or if the involved medical providers and program staff are uncomfortable with a recommendation stated within these guidelines, it is appropriate for the program manager, involved healthcare provider, and/or other local leaders (such as an affiliated infection prevention and control program or public health department) to reach a final management determination. When there is evidence of ongoing transmission or concern for a possible outbreak, more stringent infection prevention and control measures will likely be recommended by local consultants.

Staff Member and Volunteer Illness and Vaccination

Staff members and volunteers who work while ill may provide suboptimal service and may pose an infectious risk to other staff, volunteers, guests, and visitors. All family-centered residential facilities should develop policies and procedures for evaluating and excluding ill staff and volunteers. At a minimum, staff members and volunteers should report symptoms of any potentially contagious infection (eg, respiratory or gastrointestinal tract illnesses, and vaccine-preventable diseases, including chickenpox, measles, and mumps) to their supervisor. Clinical evaluation by a healthcare provider may be necessary to determine if work exclusion is recommended.

Ideally, all program staff members and volunteers should routinely consult with their healthcare providers to verify their immunization status and obtain the recommended vaccines. By ensuring staff members and volunteers are up to date on recommended vaccines, the risk of exposure of vulnerable patients and their families to vaccine-preventable illnesses such as influenza, pertussis (whooping cough), measles, mumps, and varicella (chickenpox) will be reduced. See Appendix B ("Vaccines") for further details about adult immunizations.

Breast Milk Storage and Maintenance of Breast Pumps

Human milk is the preferred feeding for all infants, and the AAP recommends exclusive breastfeeding for all infants for the first 6 months of life.[24] Mothers of hospitalized infants or mothers who must be separated from their infants because of the hospitalization of an older child may need to express and store breast milk while staying as a guest at a family-centered residential facility. Human milk is not sterile, and proper storage and handling is needed to reduce the risk of contamination and growth of microbes that could cause illness. Proper storage and handling of breast milk is an important component of a facility's food safety program.

Expressed breast milk should be stored in glass or food-grade plastic containers with tight-fitting lids. Alternatively, it may be stored in plastic bags designed specifically for human milk storage. Each container should be clearly labeled with the infant's and mother's full names and the date and time the milk was expressed. Breast milk should be stored so that guests have access only to milk that belongs to their own infants. It must be kept in a refrigerator in a guest's room or in a separate, clearly labeled, and preferably locked container in the communal refrigerator. Freshly expressed breast milk may be refrigerated safely at 4°C (39.2°F) for up to 96 hours. Milk may be stored in the freezer compartment of the refrigerator for 3 months. Thawed breast milk must be kept refrigerated and used within 24 hours.

Inadvertent administration of expressed breast milk to the wrong infant has occurred in healthcare and day care settings and could theoretically result in exposure to infectious agents, including HIV, cytomegalovirus, and hepatitis B.[25] Therefore, accidental exposure to breast milk that is not from the infant's mother is generally managed in the same manner as accidental exposures to blood.[26] The child who received the incorrect breast milk should be referred to his or her healthcare provider for further guidance. The mother who supplied the breast milk (donor mother) should be notified that her milk was inadvertently administered to the wrong child. A healthcare provider should discuss the need for HIV testing with the donor mother if she has never been tested before. The CDC recommends that the donor mother be asked how the milk was expressed and how the milk was handled before being stored at the facility.[24] This information should be shared with the parents of the exposed infant and his or her healthcare provider.

Parents of the exposed infant can be informed that the risk of HIV transmission is low from expressed breast milk because known HIV-positive women are advised not to breastfeed their infants. Additionally, chemicals present in breast milk and cold temperatures degrade HIV present in breast milk. Transmission of HIV from a single breast milk exposure has not been documented. Although hepatitis B surface antigen has been detected in the breast milk of hepatitis B–infected women, breastfeeding is not thought to significantly increase the infant's risk of infection, particularly when a birth dose of hepatitis B vaccine has been given. The risk of hepatitis B transmission from an inadvertent breast milk exposure is likely quite low.

Special Populations

In health care, highly vulnerable special populations are identified on the basis of the risk of acquiring infection and the risk of developing more serious disease once infected, compared with otherwise healthy individuals. These special populations are also likely to spend more time (eg, frequent visits and frequent and prolonged hospitalization) in healthcare facilities due to their underlying conditions. Additionally, they may have medical devices (eg, central venous catheters, tracheostomy tubes, and dialysis catheters) that make them even more susceptible to infection. Patients with weakened immune systems from congenital or acquired immune deficiency, chemotherapy, or immunosuppressive medications may not respond to vaccines or develop protective antibodies. Such patients do not receive most live virus vaccines because their immune systems may not be able to control the weakened vaccine virus. For such patients, it is especially important that close contacts be completely vaccinated to prevent exposure to vaccine-preventable diseases.

Families of patients with these special conditions are educated by the healthcare team about the precautions they need to take to reduce the risk of infection. When arrangements are being made for a family to check into a family-centered residential facility, it is helpful to ask if any restrictions have been recommended by the child's medical providers. Examples of the most frequently encountered special populations include the following:

  1. Neonates, especially prematurely born

  2. Immunodeficiencies

    1. Congenital

    2. Acquired (eg, HIV/AIDS)

    3. Asplenia (congenital/acquired)

  3. Immunosuppressive therapy

    1. Cancer chemotherapy

    2. Hematopoietic stem cell transplant (HSCT, also referred to as bone marrow transplant, or BMT)

    3. Solid organ transplant (eg, lung, liver, kidney, heart, and small bowel)

    4. Rheumatologic diseases (eg, systemic lupus erythematosus [SLE] and juvenile idiopathic arthritis [JIA])

    5. Inflammatory bowel disease (eg, Crohn disease and ulcerative colitis)

  4. Cystic fibrosis

  5. Pregnancy

Neonates. All infants are born with an immature immune system that develops throughout the first few weeks and months of life. The more premature an infant, the more compromised the immune system is at birth. Additionally, prematurely born infants with chronic lung disease or certain anatomic anomalies may be predisposed to both acquiring infection and developing serious complications of infections.

Immunodeficiencies (Congenital or Acquired). Some children may be born with deficiencies or complete absence of various components of their immune systems; these are referred to as congenital immunodeficiencies. Some deficiencies are so severe that those affected may eventually require a bone marrow or stem cell transplant. Most congenital immune deficiencies result from genetic abnormalities and can affect different components of the immune system.

There are many ways in which immunodeficiency may be acquired after birth, including HIV infection or loss of the spleen due to either disease (eg, sickle cell disease) or trauma.

Immunosuppressive Therapy. Treatments for a variety of conditions (eg, cancer, SLE, and inflammatory bowel disease) include potent chemical and biological agents or radiation that suppress the body's immune system, often used to allow the body to accept lifesaving transplants of organs, bone marrow, or stem cells. For each condition, the degree of immunosuppression and vulnerability can be predicted during the patient's stages of treatment. The most vulnerable patients are stem cell transplant patients, usually within the first 100 days following transplant or during all periods when they experience rejection of the transplanted cells (graft-versus-host disease). These patients are especially susceptible to disease caused by mold normally found in the air, particularly near construction sites or water leaks that have not been promptly repaired within 72 hours. The healthcare team can provide information about the degree of protection needed. These patients may be separated from others until their immunity improves.

Cystic Fibrosis (CF). Patients with CF are susceptible to many infectious agents and will develop a decline in lung function after infections with common respiratory viruses that may not cause serious disease in others. Compared with other patients, patients with CF require additional protection to prevent transmission from contaminated respiratory therapy equipment and from respiratory secretions of other patients with CF. Infectious agents such as Burkholderia cepacia complex and Pseudomonas aeruginosa have unique clinical and prognostic significance for individuals with CF. B. cepacia infection has been associated with increased morbidity and mortality.[12] This unusual pathogen is rarely found in patients who do not have CF, unless they have been exposed to a contaminated medical product. Person-to-person transmission of B. cepacia complex has been demonstrated among children and adults with CF in healthcare settings, during various social contacts (most notably attendance at camps for patients with CF), and among siblings with CF.[12] There is also an increasing amount of information suggesting similar patient-to-patient transmission of strains of Pseudomonas aeruginosa. Although patients with CF have traditionally found support by socializing with other patients with CF, the threat of acquiring dangerous bacteria from one another has led to recommendations that patients with CF SHOULD NOT socialize with each other. In residential houses, siblings who live together in the same home may reside and socialize together. However, nonsiblings with CF should not socialize, have meals, or room together.[12] An updated guideline for infection prevention and control in people with cystic fibrosis is in preparation.

Pregnancy. Pregnancy is not associated with a true immunodeficiency. However, there are certain infectious agents that may affect the fetus adversely if infection occurs during pregnancy. Consistent hand hygiene and avoiding sick contacts, cat litter, and undercooked meat are just some of the recommendations that will help to keep pregnant women healthy. Ideally, pregnant women who are staying in residential facilities will have been counseled by their obstetricians.