Women and children first: transforming a historic defining moment into a contemporary ethical imperative.

"Women and children first" is a familiar phrase and comes down to us from the heroic sacrifice of their lives by British soldiers on the HMS Birkenhead in 1852. "Women and children first," the New York Declaration of the International Academy of Perinatal Medicine, has defined biases in the allocation of health care resources for women and children in the developing world. In this clinical opinion, we identify challenges to the just allocation of resources for fetal, neonatal, and pregnant patients and provide ethically appropriate responses to these challenges. We distinguish substantive justice from procedural justice and identify biases against pregnant, fetal, and neonatal patients related to both substantive and procedural justice. We then identify ethically justified responses to these biases that obstetricians should adopt in reforming organizational and public policy by responsibly advocating for fetal, neonatal, and pregnant patients, whose health care otherwise is at risk of unacceptable compromise.