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Dr. Jones: Your period is late and you got the test and you're pretty sure it says that it's positive, but this pregnancy wasn't planned. What are you thinking about and how do you feel?

Well, it turns out that in the United States and around the world, about half of pregnancies are unplanned. Unplanned meaning you weren't thinking about having a baby next month, it wasn't exactly on time, but unplanned usually means that you weren't planning on having a baby any time in the immediate future.

In the unplanned category, of these 50% of pregnancies that are unplanned, about half of them are mistimed. You might say that. A woman would say that she was planning on having a baby sometime, but just not right now.

And about half of those unplanned pregnancies are unwanted, meaning the woman when asked in interviews . . . And these interviews are done nationally about every five to six years through the National Survey of Family Growth and many other organizations who try to get a better understanding of this issue. In that spectrum of unplanned pregnancies comes a spectrum of different emotions.

In the virtual Scope studio today is Jamie Hales. And Jamie is a clinical manager at the Huntsman Mental Health Institute. She's here as a social worker to help us kind of think about what are the emotional responses to an unplanned pregnancy. So thank you for being in the studio, the virtual studio with us, Jamie.

Jamie: Thank you. I appreciate you having me.

Dr. Jones: So I'll give you a little bit of my background. I'm a reproductive endocrinologist and an infertility specialist. So, clearly, the unplanned pregnancy among my infertility patients is one that's met with often surprise and joy. But I'm also a family planning specialist and I've been an abortion provider for pregnancy termination.

And the spectrum of emotions is huge in terms of people who come and are faced with a pregnancy that they either didn't want now or didn't want ever. Can you tell me a little bit about your experience and what you've seen?

Jamie: I would completely echo that experience. What I most often see in my practice is more when somebody has had an unexpected pregnancy, it's a happy thing. They're excited about it. But I 100% see people where that is the exact opposite experience.

Sometimes our society, the idea is that, as a woman, you're supposed to be extremely excited about this new journey and chapter in your life. It isn't always that way for everybody, and that's not a bad thing.

And I think something that's really important when you're working with people who are childbearing age is to be as open-minded as possible about this because not everybody's pregnancy journey is the same. There is variation all over the place, and I think it can be hard sometimes for people to admit that, "Yeah, this is something that I'm really struggling with."

Dr. Jones: We go down this pathway of healthy baby, healthy mommy, and we don't spend a little time and say, "Why don't you tell me how you're feeling about this?"

Quite frankly, I'm a mother and a grandmother, and I planned my pregnancy down to the minute, but I was ambivalent. Even though it was highly planned, I was ambivalent thinking, "My life will never be the same." And there was a little bit of worry and grieving about that, even in a very planned pregnancy.

I think it's a matter of recognizing that it's an emotional rollercoaster. First of all, your hormones are different. You are now in a potentially new social domain going forward. You will now be a new person, if you choose to continue the pregnancy, called a mother. And then there's your own emotional makeup and you don't want to do that.

Listen with an open heart. I don't know how to put that in any other way. It's rare to have someone who's so neutral that they've got nothing going on. I worry if I see that.

Jamie: That's a very good point. I think being completely neutral about your pregnancy probably is more of a red flag than having some strong feelings about it either direction.

And those feelings can change, right? One day you may be feeling absolutely fantastic about it, and then there may be other days where that is not the case. And ultimately, it isn't up to the people around you to decide what the normal range of emotion is. That's up to you.

It can be a very fraught topic, but it's also one that I think is very important for us to discuss because this is another one of those situations where you might be out there experiencing some of these thoughts and feelings and think, "Wow, I'm the only one that's dealing with this right now," or, "I don't want to say anything because nobody is going to understand." And it is much more common than I think people realize. 

Dr. Jones: So how do we begin to help women negotiate how they're feeling and what they're planning on doing, figure out what are the resources available to them?

Jamie: Resource-wise, there are a couple of groups that are done online through Postpartum Support International. They have a virtual group for medical termination and also one for post-termination support, even if it wasn't for medical reasons.

So there are really good resources out there, and I think it's important to speak up if it's something that you're struggling with.

Ultimately, at the end of the day, we're not the ones that have to make really tough choices around this. And what the person wants and how they're feeling about it absolutely comes ahead of what any of the rest of us may or may not think about that pregnancy.

If you're going to therapy, that's a really great safe space, I think, a lot of the time to bring up complicated feelings about stuff because it's confidential.

And not everybody in your life may agree one way or the other with your choice whether to continue, not continue, the fact that it happened in the first place.

There are a lot of factors that go into unplanned pregnancies. There's a change in identity. Everyone, I think, comes at it with a different background, a different degree of support and resources.

Dr. Jones: Right. And most women struggle in the sense that they are making a decision thoughtfully, and when they finally make their decision, they're usually pretty sure. But on the way, it's giving them the information that they need so that they can feel that the next 60 years of their life one way or the other is written in a way that they can feel comfortable and move ahead.

I want to thank you so much for joining us. And for everyone who's been listening, thank you for joining us on the "7 Domains."

A baby that is wanted and planned for, a child by choice and not by chance, that is what modern contraception offers men and women. But you have to know what's out there, how it works, and where to get it. This is really important now more than ever.

This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah Health, and this is the "7 Domains of Women's Health" on The Scope.

Women and men all over the world have wanted to plan their families for thousands and thousands of years, but methods used in Cleopatra's time in ancient Egypt probably weren't as effective as what is available now. If no method of contraception is used, women in sexual relationships that would make them pregnant could expect to have more than 11 babies. That's in these days of good obstetrical and pediatric care, where women are less likely to die in childbirth and babies are much less likely to die in the first five years of life. Eleven babies sound like too much? One more baby sounds like too much right now?

Let's talk about contraception. It's an egg and a sperm problem. You need to stop egg production, stop sperm production, or stop the sperm from getting to the eggs. These are the main ways that modern contraception works.

About 50% of unplanned pregnancies happen to people who are "using" contraception but using it incorrectly. This is the most common reason that methods like abstinence or periodic abstinence, think natural family planning, or methods like barrier methods like condoms or diaphragms actually fail. They weren't used correctly or at all. Methods that you have to think about at the time of sex are more likely to fail because you're more likely to fail to use them. If you combine two methods, abstain during your fertile period and use condoms all the rest of the time, your chance of getting pregnant by accident is much lower. Two methods are better than one, and this is a combo where men can be the important user. You can get condoms most anywhere, and anyone with some smarts and gumption can figure out their fertile period.

So let's talk about hormonal pills, patches, and rings. They are considered moderately effective methods or ones that have an annual failure rate between 1 in 10 to 1 in 100. That means if women use them, the chance of getting pregnant is about 1 in 10 to 1 in 100 per year. Of course, you might be at risk for pregnancy for multiple years, so these chances literally add up. Considering a lifetime of contraception using these methods, it was calculated that women would have about two unplanned pregnancies. These methods work by blocking ovulation and by changing cervical mucus so sperm cannot get to the eggs, but women don't always take the pills, or patches or rings correctly. They miss some days or they stop for a week as directed, but they stop for longer than seven days, and they are very likely to ovulate. But you could team up with your sex partner and use a moderately effective method and condoms and get much more bang for your buck birth control-wise.

Hormonal methods aren't right for everyone, and you should know by reading up or asking knowledgeable clinicians if they're right for you. Now, there may be immense hormonal contraception on the horizon, transdermal hormones to block sperm production. If it has about a 10% failure rate per year, and women taking the pill as they will, not perfectly, have a failure rate of about 10% per year, if both members of the sexually active couple use the method not perfectly, the failure rate would be about 1 in 100 per year. The two methods multiply in terms of their effectiveness. If they both used effectively, if they both, men and women used hormonal methods effectively, it would be about 1 in 10,000 women per year, and that is effective contraception.

Now for highly effective methods, these methods have failure rates of about 1 per 1,000 women per year. They are so good because you don't have to think about them and using them correctly almost always happens. These include copper IUDs, hormonal IUDs, and hormonal implants under the skin. The hormonal implants' primary method of action is to work by blocking ovulation. The IUDs' primary method of action is by blocking sperm. Copper in the copper IUD kills sperm on their way up to the egg, and the hormonal IUD blocks sperm from getting through the cervix. The IUDs and implants are highly successful at preventing pregnancy but require a trained clinician to put them in. They last a long time, the copper IUD for 12 years, the hormonal IUD for 5, and the implant for 3, but they are immediately reversible as soon as they come out.

Now, all contraceptive methods have some side effects and risks, but none have as many risks and side effects as an unwanted pregnancy. Uh-oh, did you just say, "Oops?" Did you forget to take your pills? Did the condom slip off or stay in his back pocket? Was sex forced on you and you weren't using anything? Emergency contraception is for people who had unprotected or under-protected sex. They are pills over the counter or by prescription, that must be used in the first three to five days after the unprotected sex act, and the earlier, meaning the next day or the day after, the better. The copper IUD and hormonal IUD can also be used for emergency contraception, but they aren't FDA approved for that use, and you have to find a clinician to place one in a timely manner.

Using contraception means some work on your part. You have to know what you can use and want to use. You need to know where you can get them. You need to know how you can pay for them. All this information is available from many sources, but an overall good resource is bedsider.org. Many clinics around the country provide contraception on a sliding fee scale based on the ability to pay. Most insurance plans pay for a significant amount of the cost of contraception. There's a national family planning grant called Title X, that provides low-cost contraception to anyone who needs it, and it's available in most states. But you have to lace up your boots or put on your flip-flops and do it. Children deserve to be by choice and not by chance now more than ever. Thanks for joining us on The Scope.

Interviewer: We're with Dr. Stephen Fenton. He is the founder and director of the Utah Fetal Center at Primary Children's Hospital. And it is for women who have high-risk pregnancies due to a congenital anomaly with the child. There is kind of a way things used to be done. And now there's a way things are done at the Utah Fetal Center, Primary Children's Hospital, which is a much better way. Dr. Fenton, first of all, you're the founder and the director. You came in and you said, "I want to start this center."Why did you say that?

Dr. Fenton: I don't want anyone to ever think or believe that what was happening before wasn't being done to the best of its ability because it certainly was. All of these conditions were being cared for before. But the reality is it was kind of done in what I would term a physician-centered approach. So oftentimes that would require multiple clinic visits because they were separate clinics in each of the physician's clinics. And you can imagine how frustrating and how hard that must have been for that mom to kind of shoulder that burden all on her own.

Interviewer: It was a very stressful time.

Dr. Fenton: Very stressful time.

Interviewer: Just to coordinate her care kind of.

Dr. Fenton: I mean, and during all that time, of course, worried about her unborn child. And so what we've done is we've kind of shifted it from this physician-centered care to what I term patient-centered care with a multidisciplinary approach. So we, over the last five years, have put together a multidisciplinary team of all of these specialists that care for the child and for the anomaly. In addition, we've added adult specialists, so maternal fetal medicine or high-risk OBs that care for the mom, all in one place. We didn't have adult providers at the Children's Hospital. Now we have these adult MFM providers who help care for these moms. We also added a coordinator. We've added nurse coordinators that actually help the mom wade through all of this, and ancillary staff, such as a social worker, who can also help with the non-clinical aspects. We are now all in the same place. Instead of being in our individual silos, if you will, we're all located together where we can look at the images together, where we can talk about it, and where we can come up with a care plan not only for the mom until baby is delivered, but also for the child after delivery.

Interviewer: What is the objective of the center?

Dr. Fenton: We want to make sure mom and baby first have the right diagnosis. It's much easier to help the parent learn what the condition is and start understanding what the treatment, if any, will entail before the child is born. Now that's one aspect. The other aspect is some of these kids need intervention before they're born. And in order to do that, it's very specialized. It requires a team and it requires being able to take the mom to proper diagnosis and from diagnosis to intervention, and then from intervention to delivery safely. And you can't do that without proper infrastructure, and the Utah Fetal Center is that infrastructure.

Interviewer: Can you give me an example of a couple of the common conditions that you would require that would require this multidisciplinary team?

Dr. Fenton: Congenital diaphragmatic hernia is one that comes to mind, myelomeningocele, that's another word for spinal bifida, CPAM or congenital pulmonary airway malformation also known as congenital lung lesion, atresias, intestinal atresias, omphalocele, gastroschisis. These are all things that are surgical too. We oftentimes see kids that don't necessarily require surgery. So some of the genetic disorders like trisomy 21. We also see kids that have neurologic issues, so brain malformations that won't necessarily require intervention, but will require a coordinated care with multiple providers.

Interviewer: What does that initial consultation entail when they come to you? What does that look like?

Dr. Fenton: In the morning, they oftentimes will undergo an ultrasound and consultation with one of the maternal-fetal medicine physicians that work at the Utah Fetal Center. Dependent on what the original diagnosis is, and oftentimes we have already received outside imaging from the referring providers and reviewed it, they might also undergo a fetal MRI, and that fetal MRI will give us even more detail, especially when we can compare it to the ultrasound that happens on that same day. It's read by the fetal radiologists that work in the center. And then usually we give them a little bit of a break. They go to lunch, etc., and then come back in the afternoon or early afternoon, and there, they will see the specialist, the sub-specialist that will ultimately care for their child.

Interviewer: If a patient wasn't referred and they believe that the Utah Fetal Center is the place that they would like to go, are they able to call?

Dr. Fenton: Absolutely. They can go to our website, utahfetalcenter.org and self-refer. We really want to help these parents get through this very, very difficult time. We understand that there are a lot of providers out there that are doing a portion of this, and we certainly appreciate all that they are doing. We are not looking to just assume all care of these moms because we know that a lot of their care can be delivered close to home, but we do feel like it's very, very beneficial to start that coordination of care early so that we can help the parents understand what is happening, obtain expectations on the treatment plan, as well as understand the treatments involved and then initiate that plan early, and in the long run we know that doing so with the help of the many providers, not only here at the University of Utah and Primary Children's Hospital, but across the state will allow us to do that.

Dr. Gellner: Teen pregnancy. It's something I see more than you'd think. So what's going on? Is it lack of parent involvement in a teen's life? Are kids too embarrassed to talk to parents about protection?

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Dr. Gellner: According to the American Academy of Pediatrics, more than half a million teen girls become pregnant every year. They even have set out a policy statement on helping to counsel pregnant teens to make sure they get good medical care and information about their options while still being respectful of the families involved.

In my experience, teen pregnancy doesn't have a set demographic. I've taken care of teens who've become pregnant or who father pregnancies from all walks of life, from affluent families, Medicaid families, foster families, families where teens have good relationships with their parents, families where teens have very strained relationships with their families, teens who are "good kids" and teens who have been more difficult to control.

I've seen it in families who are very much against birth control and who promote no sex until marriage, and in families who are very open about sex and birth control. I've had to tell teens aged 16, 14, even a preteen 12-year old that they are pregnant.

Bottom line, there is no age or social situation that can predict teen pregnancy. Of course, the only thing that prevents teen pregnancy with 100% effectiveness is teens not having sex at all. However, we know teens and we know how their hormones are. If a teen wants to have sex, they will most likely go ahead and have sex. The more taboo it is in the family though, we sometimes find the less likely the teen will talk to someone about protection.

Again, sex doesn't just cause babies. It causes sexually transmitted diseases too. There is less and less sex-ed in schools today, and while kids should be taught the basic biology of sex as part of health class, they really need to get the bulk of sex-ed from their parents. They need to know what their family values are about sex. They need to feel comfortable talking to their parents about sex if they have questions so they don't get misinformation from their teens.

Trust me, I've heard some pretty strange things out there from teens. Pretty much all pediatricians are comfortable talking with teenagers about sex even if their parents aren't. In fact, it's something we start talking about at the 12 year well visit in my clinic, mainly to bring awareness to the parent and the patient. To say, "Hey, guess what? Your teen and their body are going to change a lot in the next few years, and we really want to help open the lines of communication so your teen knows that if they have questions they can talk to someone." Talking about sex won't make your teen go out and do it, nor will it prevent them from doing it, but it just might prevent a teen pregnancy.

If your teen is sexually active, most pediatricians are comfortable discussing birth control options. If your teen becomes pregnant, it's very important for the health of the teen and the baby to get medical care right away. Your teen's pediatrician can help you find an OB that works with teens.

Bottom line is teen pregnancy has always happened and will continue to happen, but the health of the teens and the babies needs to be top priority no matter what the situation.

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Dr. Jones: What would the life of women and their children look like if every woman had the information and ability to plan every pregnancy? This is Dr. Kirtly Jones from obstetrics and gynecology at University of Utah health care, and this is The Scope.

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Dr. Jones: In the United States, almost half of all pregnancies are unplanned. In about half of those, the unplanned pregnancies were mistimed and about one-half of those pregnancies were unwanted. What would happen in the lives of women if they had all the information they needed to make a careful decision about pregnancy, or contraception, and they could get any method of contraception they wanted for free? Dr. Turok is a clinical professor in the Department of Obstetrics and Gynecology here at the University of Utah and a specialist of family planning.

Welcome, Dr. Turok. What happens in young women's lives when they have an unplanned pregnancy?

Dr. Turok: The largest group of women who have abortions in this country are those who have unintended pregnancies and as you mentioned, it a lot of people. It's over a million women a year. And for women who continue with a pregnancy, pregnancy is a chaotic time, as is child rearing, and if you're not planning for it from the get go, it further complicates things.

A population of people who have had planned pregnancies and a population of people who have had unplanned pregnancies and the children thereof, the kids from unplanned pregnancies are more likely to be born premature, to end up in the newborn ICU, to have less medical care in their first year of life, to do less well in school, and to not finish school.

Dr. Jones: So there are good reasons to build a structure around which families can be planned. We all want the kids that come to us, we don't all, but most of us want the kids that came to us because we, after the fact, create this incredible story about our kid was the miracle we didn't planned, but we love. But there are consequences to having babies that aren't planned.

Dr. Turok: There certainly are. The best predictor of having loving parents around to care for a child is to have been planning for that child from the beginning. And it's such an important predictor of how well children do that anything that we can do to help people time their pregnancies so they end up with the children they want, when they want them, only helps everybody.

Dr. Jones: In other countries, I know Europe does a pretty does a good job, people in Scandinavia do a pretty good job planning their children. What's keeping us in the U.S. from planning our children? Why do we have the highest rate of unplanned pregnancies in the Western world?

Dr. Turok: The difference between Scandinavia and the United States are many things. It's sexuality education, it's the conversations that children and young people and their parents have regarding the expectations for intimate partners. And it's the availability of contraception. In Scandinavia many more women use the most effective, reversible methods of contraception like IUD's and implants. And what we've seen in the United States in the past decade is that as communities and states have broadened the availability of these most effective methods, the rates of unintended pregnancy and abortion have plummeted.

Dr. Jones: What is it about America? Is it that we are a multicultural country? Because we don't have a unified healthcare system? Is it because we have diversity in income across the country? We have people who are truly poor. Why are we different than the Scandinavians, other than we don't have as many blonde people?

Dr. Turok: The biggest thing we see in disparities of unintended pregnancy are along socioeconomic lines, and race and class, and women of color, women who have completed less education, women who have fewer financial resources, are much more likely to have unintended pregnancies. In making opposites available and really removing all barriers to obtain methods of contraception will aid those people in determining when and if they have children.

Dr. Jones: We still have to reach out though to women. Women have to be thinking about contraception rather than just saying "oops", or, This is just what happens to me, and it happened to my mother and it happened to my sister." So how are we going to reach out to a vulnerable population of women here in Utah, here in Salt Lake County, to get their attention and say, "Are you sexually active?" Or whatever that means. "Do you want contraception? Do you want it for free? Come and see us." How are we going to reach out to the people who don't think they're going to get pregnant?

Dr. Turok: We've been working on this for quite some time, and the number one place people who want to initiate contraception, who have barrier of obtaining it come to in Salt Lake County is Planned Parenthood. So that's why we are collaborating with the four Planned Parenthood clinics in Salt Lake County to provide any method of contraception that women want that's offered at those clinics for free. And that includes the most expensive and the most effective methods, which are IUD's and implants.

Dr. Jones: And women who come in, they can get their method for free, but some of them actually might be willing to let us contact them in the years to come to see what happened with their lives using whatever method they chose.

Dr. Turok: Right. So we've started this project called "HER Salt Lake," or the HER Salt Lake Contraceptive Initiative, and what it does is we have three six-month periods. The first period is just the way it has been for very long, where people essentially have to figure out how they're going to get their method and pay for it.

The second period we eliminate all the costs. You walk in, you get the method you want, regardless of the ability to pay. And you don't pay anything.

And the third six-month period, we have a media campaign where women 18-29 years old will receive information on they had held devices that promotes the information about IUD's and implants and connects them with the places where they can get it for free. It'll be on Facebook, it'll be on Twitter, but it'll also be on pop up ads. It'll be modulated along the way to optimize the message and the way people receive it and when they get it. It requires a lot of community support, and support from outside resources, but we can get this done and we're working on creating a durable solution for this.

Dr. Jones: Years ago we had a picture of a pie which looked at the pregnancy outcomes in this country with the unplanned rate at a little over 50%, and for years and years that didn't budge, and you told me that your life's work was going to be to move the needle. How do you think it's going?

Dr. Turok: Yeah I think what I said was, if the shape of the pie doesn't change during the course of my work life, I'm going to be really upset that I didn't spend enough time skiing with my kids.

Dr. Jones: Dr. Turok, thanks for joining us and thank you for moving the slice of the pie that will be afforded to children who've been planned.

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Interviewer: Dr. Stephen Jay Fenton is a pediatric surgeon and also an expert in congenital diaphragmatic hernia. So, most of the time, it's diagnosed before the woman has given birth. So, this diagnosis comes in, what are some considerations that the woman, the mother, the family are going to have to do at this point?

Dr. Fenton: Once this woman has diagnosis they need to be referred to a maternal fetal medicine physician, so someone who deals with high risk pregnancies. And one of the things associated with that is that they need to be followed closely during their pregnancy. One is to ensure the safe delivery of the child and then also in preparation as far as what will happen once the child is born.

I think it's important for the mother to know that this is something that will require treatment for a long time after the child is born. So I typically would say three, four, to six months afterwards, that child will need to be in hospital that takes care of these types of kids. And so sometimes it might require relocation or making sure they have a support system away from their house. For example, if they live quite a bit away from the children's hospital that deals with this specialty, they may need to start thinking about the Ronald McDonald House or finding some other place that they can live.

Interviewer: Wow, so this diagnosis is a serious thing.

Dr. Fenton: Yeah, I mean over the past 10 to 20 years the survival rate has improved, but it still is one of those diseases that takes a lot as far as to treat the child once they're born and then afterwards to help the child continue to grow.

Interviewer: What's the conversation that you have with these families? Take me through that conversation, some of their concerns, their questions, the things that you tell them that are important to consider.

Dr. Fenton: So, after getting past the basic questions of what is a diaphragmatic hernia and how is it treated, the things that I really focus on are we need to find out a little bit more about the child. So, one of the things that we'll get when they come to our office is what we call predictive or prognostic predictors.

So, a lot of times they will have already undergone ultrasounds, several ultrasounds, to look further at the child. One of which is of the heart, so a fetal echocardiogram. We want to know whether the child has a congenital heart disease as well because that does complicate things when the child has not only a diaphragmatic hernia, but has congenital heart disease as well. They are at a much higher risk of not surviving.

And it also limits some of the things we can do, especially as far as the ECMO or the heart lung bypass, if the child has a structural heart defect we can't put them on ECMO. So, the families need to know that.

Additionally we want to know what their chances of going on ECMO are and what their survival ability is. So, we look at these different things. One is the lung to head ratio, which is obtained by the ultrasound. Then the other is the total lung volume which can be obtained by the MRI. And those, depending on what the lungs look like, so the ratio of the lungs to the heads and/or the observe to expect of total lung volumes.

We can give parents the percentage of whether their child is going to require ECMO support and/or what their survivability is. And so the parents, when I talk to them, I almost talk to them much more about the support that the child will receive before and after repair, than the repair itself. Because the repair is really a step and only one of many steps in the care of the kid once he's born.

Interviewer: Wow. So, how do you help parents take all this information that you just talked about, head-lung ratios, and how do you make them make sense of what they should do at that point?

Dr. Fenton: Well, I think it's hard, especially for the initial visit, because a lot of information is given and so we will talk to them upfront and then we'll see them once they come into the hospital again to give birth. And talk to them once the child is born as well, and we can gauge. Obviously all of these are predictive.

They're not definitive and so it's after the child is born that we see how they're doing, that we kind of give them a little bit more of a definitive plan as to whether we feel like the child's going to need ECMO or whether we feel like when the child can be repaired. And some of the consequences as far as neurologic cardiac long-term pulmonary support. A lot of times we can't necessarily give them that until we are in the midst of taking care of the child.

Interviewer: What options do parents have at this point?

Dr. Fenton: I honestly refer my patients out to websites as well. "I feel like I've given you a lot of information. We want you to know more." There are support groups, CHERUBS is one, as far as the parents can Google. I also had them look at WebMD. I've actually found most parents to be very well informed when they come in even to the prenatal interview. So the very first kind of clinic visit that we have, I found that most parents who come in have already read up quite a bit about it.

Interviewer: Yeah, because they were told about the diagnosis and they're very curious and want to know.

Dr. Fenton: Exactly. And I think that helps. I mean having the parents be informed already about what it is and having specific questions as far as okay, so, tell me about ECMO. Tell me about reflux, and tell me about when you're going to do the repair and what the repair options are. It helps with the conversation already.

Interviewer Do some parents at this point after they get this information choose not to continue the pregnancy if they think... if you think I should say, it's going to be really bad?

Dr. Fenton: Some do. Yeah. I mean some will discuss options of whether to be able to continue the pregnancy or not. Obviously depending on the gestational age of the child, that might not be an option anymore. More often what is talked about is palliative care. So, meaning how aggressive to treat the child afterwards and how much should be pursued.

I would tell you that most parents say, "I want everything done. We'll go forward and certainly want to help the child, after they're born in whatever way is possible." But there are some times where we can't do that. And so I think it's important to have that discussion before, of what are the limits and the possibility of needing to do either palliation immediately after the child is born. And/or when have we exhausted all medical means to help this child.

Interviewer: So, after a diagnosis of CDH, can a child live a normal life after you've done what you needed to do to rehabilitate?

Dr. Fenton: Yes, I think that's the key. We've done what we needed to do rehabilitate or to treat the child, and obviously there is a pretty high mortality associated with CDH now. It has improved greatly over the past two decades. But it's still a serious disorder. There are some kids that have lungs that are so small and so underdeveloped that we're not able to treat those.

Now, the children that we are able to treat, they can go on and live a very productive lives. Some of them may have some challenges secondary to the treatment themselves. They might need oxygen support. They might not be able to exert themselves as much as a consequence of treating their underdeveloped lungs. But most of them can go on and live great lives even if they require some support.

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Dr. Jones: When should a baby be born? It's sort of a Goldilocks problem isn't it? When is too early? When is too late? And when is just right? This is Dr Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care. Today we are talking about when should babies be born, on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Jones: So how do you know when an apple is ripe? Just right. By color? By size? By season? Do you pull it off the tree? But if you're wrong you can't put it back. Do you wait till it falls until the tree thinks it's ripe? Well then it might get bruised. So is it the number of days? How do you calculate them? When is too early? When is too late? What about babies? When do we know that the baby is ripe?

Today we're talking with Dr. Erin Clark a perintologist, that's someone who specializes in high risk pregnancy, about when is the baby just right. Welcome to The Scope Dr. Clark.

Dr. Clark: Thanks for having me.

Dr. Jones: So how do we know when a baby is ripe? Is it 40 weeks? Is it nine months exactly? Is it certain amount of days? And how do we get that number?

Dr. Clark: The formal definition of when a woman is due is 40 weeks from the first day of her last menstrual period. We know generally that that's the date because that's around the time when most people spontaneously go into labor. We have great respect for when Mother Nature does it right. Certainly Mother Nature doesn't always get it right and outcomes for moms and babies are not always good. Ten percent of babies in the United States are born too early, but most of the time delivery occurs about that 40 week mark.

Dr. Jones: So when is it too late?

Dr. Clark: It's a complicated question but if we look at outcomes for moms and outcomes for babies, a variety of outcomes. Stillbirth, c-section rate, the ability of a baby to breath and do well after delivery. If we look at all of those outcomes, the lowest risk time, the sweet spot, so to speak, that perfectly right apple seems to happen at 39 weeks give or take a week or so. So between 39 and 40 weeks appears to be the lowest risk time.

There's very good data that suggest if we go before 39 weeks electively, sometimes there's a very good medical reason to do that, but before 39 weeks babies have more difficulties after birth. They can have difficulty regulating their temperature, they can difficulty with eating, they can have difficulty with breathing. We know that in a well dated pregnancy at 39 weeks or beyond, babies do really well.

There is a point though at which pregnancies can go too far and it's a gradual increase in risk that happens after the due date which is at 40 weeks. So again that sweet spot appears to be 39 to 40. In general we try to get women delivered about a week past their due date at the latest because those risks start to climb.

Dr. Jones: So what are those risks?

Dr. Clark: For babies there is a risk of stillbirth that climbs over time. That's the biggest and scariest risk because a baby who has a stillbirth does not survive to have any of the other outcomes. But there's also a high rate of c-section because the placenta while it's miraculously marvelous organ, it has a life span. And after the due date it starts to baby and labor is a stressful process for babies and if that organ is not functioning optimally, we see signs in labor by watching the baby's heart rate that the baby is just not getting the oxygen and nutrients that are necessary and so the c-section rate is higher.

There is also some other risks that are higher for moms. The rate of hemorrhaging associated with delivery, the rate of having a baby that doesn't fit because of size. Those things go up over time too. So when we look at those myriad of complications, all of them are at their lowest risk at that 39 to 40 week mark.

Dr. Jones: But it's not always so easy. So if you decide 39 to 40 is a good number, how do we get the baby out then?

Dr. Clark: Maybe this is the apple and the worm analogy.

Dr. Jones: Okay.

Dr. Clark: There's very good data, 39 to 40 weeks baby is ready to come out beyond 39. But the other question that you're getting at is when is mom ready? Sometimes the two are not in sync. But what has been shown is that if you don't induce labor in a timely fashion after the due date has passed, actually the c-section rate goes up and not down. The cervix is like a fist, before labor starts, it's hard, it's somewhat unyielding and as preparations for labor happens it gets softer.

Dr. Jones: Well that's a good thing because we want to get the baby in for those 40 weeks or 39.

Dr. Clark: Correct. It's appropriately unyielding. But as preparations for labor made it gets soft, it get thinner, it starts to open. These are signs that we like to see as women get ready for labor and even in a patient who has a cervix who's not quite ready, if they're going past their due date especially a week or more, we know that their lowest risk are to induce labor rather than wait.

There's the other question though of when is the earliest that's safe to induce labor without a medical indication? And 39 weeks appears to be the earliest based on what we talked about as far as risk for baby go up if we go any sooner than that. In a woman whose had babies before who has a cervix that is soft and ready for labor and who is known solidly to be at least 39 weeks gestation, induction of labor electively is felt to be a very reasonably medically safe practice.

What is less well known and what we need research is what about the woman who has not had babies before? There's many advocates, experts across the nation who say because of this data that suggest that 39 weeks is that lowest risk spot, maybe that should be a policy. Maybe we should induce everybody between 39 and 40 weeks because we know we would see less stillbirths, we would see less pregnancy complications like preeclampsia. Maybe that's the right approach.

Clearly there's a lot of push back saying Mother Nature, Mother Nature. We should let most of these labors go on until there's an indication to intervene. But it's still a big question, and it won't be answered until we take a group of women who have not had a baby before and randomly assign them to either watchful waiting. Seeing if they go into labor on their own and intervening if there's a medical reason. Or another group of women where when they hit 39 weeks and we say it's time to have a baby and regardless of what your cervix says as far as readiness, we're going to give you the medications that will stimulate labor.

Dr. Jones: So this is study that's ongoing?

Dr. Clark: This is a current study. This is a national multi-site study. In Utah we have several participating sites one of which is The University of Utah, one of which is Intermountain Medical Center in Murray, LDS Hospital in Salt Lake City, Utah Valley Regional Hospital in Provo, and McKay-Dee Hospital in Ogden. We are trying to enroll 6,000 women across the nation for participation in the study.

Dr. Jones: Are ladies anxious to sign up? I am assuming randomization is 50/50.

Dr. Clark: It's 50/50.

Dr. Jones: When they randomized and they get not the arm they wanted, are they doing okay?

Dr. Clark: Yeah, we have two camps of women. One is very much wanting spontaneous labor to happen. They want that story of my water broke in bed one cold winter night. They can tell over and over again to this child forever. They want that natural course. And they're not interested in participating and that is totally fine.

There's another group of women who says for logistical reasons this would be a really nice thing to have a time delivery about a week before my due date and there's some enthusiasm there for participation. Remember this is a group of women who are not eligible otherwise to have an elective induction a week early who, yes, are very interested in participating. The ones who are very much often want to be in that induction of labor arm and there are sometimes tears when they randomize the other way but again it gives them a chance at that earlier intervention whereby they wouldn't otherwise. So for some women it is a very nice option.

Dr. Jones: To round up, it sounds like you want your baby just right and somewhere between 39 and 40 weeks is, we think for babies, just right. Up to 41 is kind of practice now but maybe sooner is better. People, if they're having their first baby and want to contribute and they deliver at those places can sign up and hopefully you'll have a perfect little apple for Thanksgiving.

Dr. Clark: Right. That's the goal.

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Oh, little bits of dirt that you breathe that get into your body and affect your baby. Air pollution in pregnancy: What do we know and what should you do?

You thought that your lungs filtered out dirt and the placenta filtered out bad stuff? Well, that's sort of true, mostly true, but not completely true. Recently we've had yellow air days and orange air days and even a red day. What does this mean to you if you're pregnant, and what happens to you and your baby on a red-air day? And what can you do about it?

In Utah and across the west, we settled our towns in valleys where there was water. That was a good thing, right? And the towns grew and the cars were invented and industry grew and that was a good thing, right?

Well, we know in the past London, England had some of the worst air quality episodes in the world. And we know that people died when air got that bad. So what's happening in the Salt Lake Valley, a city in a valley prone to air inversions and when you have to breathe what your car and the refineries have pooped? Bad air has a lot of bad stuff to it-ozone, sulfur dioxide, nitrogen dioxide, and particles of incompletely burned stuff, the thing I so inelegantly called poop.

From your cars, from your favorite barbeque place, from the big industries, and from refineries. The incompletely burned particles come in different sizes, but the worrisome ones are very small, and they are called PM2.5 and they are too small for your lungs to clean and they get into your body and inflame your body and your placenta.

It is hard to do research on pregnant women. In fact, we're specifically told we have to be very careful doing research on pregnant women. And it's really hard to put pregnant women into a controlled room and expose them to various amounts of bad air. And some women get good air. And then see what happens to their pregnancies and their babies. We do have research from areas with bad air that look at pregnancy outcomes and children's health. California has been very active and looking at outcomes of pregnancy and bad air. Women exposed to bad air, living close to a freeway when they were pregnant, had smaller babies and more premature babies. And their children had more asthma and more autism.

Can we prove it was the bad air or something else, like freeway noise instead of bad air? This is hard, but here in Utah we had an experiment in Utah County about 20 years ago. We used to have really bad air when Geneva Steel was open, so we could look at outcomes when it was open and when it was closed. One specific outcome, prematurity, was a lot worse when it was open.

So what do you do if you're pregnant in bad air days, on orange days or red days? I'm not suggesting that you get in your car and go to Park City; that just makes air worse. And in recent years, the bad air has traveled up to Park City anyway. So don't drag your bad air up to Park City. You should never use a wood fireplace or wood-burning stove when you're pregnant. The air quality inside is many, many times worse than the worst air day.

I hope staying inside on bad air days helps, but our inside air comes from outside. There is some research that home air filters that can filter PM2.5 might make the air better in your home. There will be more information on this in the future as we get better small air quality measuring devices and the U is funding research just for this purpose.

Don't use your snow blower. It's a very inefficient high polluting engine. Get someone to shovel your snow.

Stay off the road; air quality on bad days is worse next to the freeways. Minimize your trips, not just for you but also for everyone, and don't wait for bad air day to limit your trips. Don't idle your car. The Utah Department of Air Quality has predictions about the next few days; act now to make tomorrow's air better.

Google the Utah Air Department of Air Quality or you can go to Airnow.gov and get a look at the country and click on Utah.

So pay attention to the air quality and the Department of Air Quality's predictions. Be an advocate; let your local and state representatives know that you're very concerned about Utah air quality; you're willing to put up with tighter controls for cars and industry, and you vote. And don't hold your breath; you're breathing for two.

updated: February 18, 2020
originally published: March 13, 2014