Search for tag: "pregnancies"

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.

Dr. Jones: If you or someone you love is pregnant or considering getting pregnant during the COVID-19 epidemic, what do we know about this virus and its effects on pregnancy?

Viruses are not all the same. And when it comes to pregnancy, some viruses like the measles virus can cause birth defects in the fetus and some like the chickenpox virus can make pregnant moms really sick, which is bad for the baby, and some like the common cold are just a nuisance. Imagine sneezing when you have a big baby's head on your bladder. Well, what do we know about the COVID-19 virus in pregnancy? Of course, we can't take a bunch of women who are pregnant and randomize them to getting the virus or not and see what happens. So how do we find out? With us today is

Dr. Torri Metz, a specialist in high-risk pregnancy, a perinatologist, and chief of the division of OB-GYN research at the University of Utah. And thanks so much for taking some time for us in this very complicated time. Dr. Metz.

Dr. Metz: Oh, thank you so much for having me. I appreciate it.

Dr. Jones: So how did you find out about the effects of COVID-19 in pregnancy? Ask one lady in your clinic or sure it was a big deal?

Dr. Metz: We actually just completed the first phase of a large multi-center study looking at the effects of COVID in pregnancy. For the study, we ran it through the NICHD Maternal-Fetal Medicine Units Network, which is funded by the National Institutes of Health. And as part of that network, we have 14 states that are represented with 33 different sites. And from those sites, we did an observational study where we collected all of the women who were pregnant with a positive test for SARS-CoV-2 which is the virus that causes COVID-19 in both the inpatient and the outpatient setting, and then we abstracted detailed information from their medical records to look at how COVID affects pregnancy and how different disease severity with COVID-19 affects pregnancy outcomes.

Dr. Jones: So these were women from all over the country, right?

Dr. Metz: Yes. Yep.

Dr. Jones: And different racial and ethnic groups and levels of income and education and everything.

Dr. Metz: Yes. The MFMU really does have representation across all of those different groups. And I think that's one of the nice things about this study is that it gives us information for women across the United States and not just in one place.

Dr. Jones: Okay. Well, how did COVID-19 infection affect the pregnant women, the women themselves?

Dr. Metz: Yeah. So that's an excellent question. You know, we found that when we broke patients down by disease severity that about 12% of these pregnant women who tested positive for the virus had either severe or critical COVID-19. Meaning that in those cases, patients typically require hospitalization because they're requiring things like oxygen support. And so, we were surprised that the proportion was that high that would require hospitalization because they became that ill.

Dr. Jones: Right. And so if you age control, so for women who aren't pregnant of the same age, the rate of severe or critical illness, is it 5%? What is it in the general population of women who aren't pregnant?

Dr. Metz: Yeah, it's a little bit hard to compare these data just because we actually used NIH classifications for disease severity, which have not been used in all of the studies, but we do know that pregnant women are at higher risk of needing things like going ICU admission, requiring a ventilator to help them breathe, and of death. And so, you know, we were expecting that it would be a little bit higher, but 12% is a decent proportion that required hospitalization and is higher than that, which is estimated in the general population.

Dr. Jones: Yeah. No, that's critical. And when I think about the moms and, you know, especially this later in pregnancy was where you got a lot of this information for women who were far along, it's hard to breathe when there's so much baby in there.

Dr. Metz: Yes, that's definitely true.

Dr. Jones: Well, so then how did COVID-19 affect the fetus?

Dr. Metz: So we think that really did have effects on both moms and babies. And really though those effects were mostly isolated to the patients who develop severe or critical illness and we really didn't see the same adverse effects in patients who had mild to moderate illness or those patients who maybe had a cough or runny nose and got tested and had SARS-CoV-2 virus, but didn't get ill.

Dr. Jones: Okay.

Dr. Metz: And those women who got more sick who did have severe or critical illness and needed to be hospitalized, the rates of them having complications were very high. And so, very often, they needed a cesarean delivery that happened about 60% of the time, and those patients that had severe or critical illness, they also developed more frequently high blood pressure in pregnancy that happened about 40% of the time in those patients. And then in terms of the babies, about 40% of them were delivered prematurely and required neonatal ICU admission.

Dr. Jones: It wasn't so much that the virus made the baby sick or cause birth defects. It was that the fetus was growing in a critically ill mom. And so that made the baby have to be prematurely born or had fetal distress. Do I get that right?

Dr. Metz: Yes. That's all right. You know, these patients, really the majority of them that we studied were in their third trimester of pregnancy because we wanted to study birth outcomes. And so they needed to have delivered by the end of July to be included in the study. And so, really at that point, it was really only women who were late in pregnancy that had contracted SARS-CoV-2 and would have delivered by that time. We still don't really have information about things like birth defects because we have not yet been able to follow enough women who would have had an infection in the first trimester all the way through delivery to be able to look at that.

Dr. Jones: Okay. Well, so now what are your recommendations to women who are pregnant as we're still in the middle of this pandemic? Now you have this information and in your own clinic or when you talk to your colleagues, what are you recommending to women who are pregnant?

Dr. Metz: I think this comes up in a couple of different settings. One is, you know, when patients do develop COVID-19 infections during pregnancy or acquire COVID-19 infections, they have questions about anticipated outcomes. And I think that we can tell patients who have mild illness that we aren't seeing a signal for adverse outcomes in those pregnancies, but I think that we still need to really be telling pregnant patients that they need to do all they can to avoid contracting the virus during pregnancy because a substantial portion of them will go on to get severe and critical illness. And those patients definitely do have increased risk of adverse pregnancy outcomes. And so, encouraging patients still wearing a mask at all times when they're outside, really trying to keep that bubble around them small, and practicing really good hand hygiene.

Dr. Jones: Now, this is more personal, Dr. Metz, but you've been actively caring for women during this pandemic in clinic and you've been on labor and delivery and you're in our own home institution. And how are you and your family doing and staying safe during this time? You come and go, you see people who are pretty sick.

Dr. Metz: Yeah, absolutely. I mean, honestly, it's just about following those same practices that we recommend to everyone in the public. I mean, as healthcare providers, you know, there are sometimes special precautions that we take especially when we're taking care of somebody that we know has an active infection, but outside of that, it's doing all the things that we're asking everyone else to do, wearing a mask at all times and washing my hands many, many times a day, and having my family do the same in our interactions with each other. I think it's a hard time for everybody, but we have good information now about how this virus is transmitted and know ways to help stop transmission.

Dr. Jones: Well, thank you. That's really helpful because people who are making decisions about whether they're going to go out into the world or whether they're going to want people not to come in without a mask or not have people come in who are outside their family, these are important things that we can use to help women make those decisions and maybe even it might help inform them if they are deciding to be vaccinated or not.

Dr. Metz: That absolutely has come up as well. I think as people are starting to think about vaccination and pregnancy, a lot of patients have questions about that and this is another piece of that puzzle and counseling that we can give patients about the frequency of increased disease severity and what we expect in terms of pregnancy outcomes with this virus. So I think it can weigh into those conversations as well for sure.

Dr. Jones: Yeah. Those are critical conversations I'm sure that you do many times a day as well. Thank you. Now, for those of your listening for you and your doctor, knowing about the risks of COVID-19 in pregnancy gives you the information that can help you and those around you be more careful about exposures and can help you to seek testing and care early if you have symptoms. So thanks to Dr. Metz for her time. And for those of you listening, stay safe out there, and 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.

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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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Dr. Kirtly Parker Jones: America is not the best place in the world to become a mother. Fifteen years ago, the U.S. was number four in the world in terms of newborn and maternal safety, and now we're 31st in the world. The risk of dying in childbirth in the U.S. is now equal to that of Iran. What's happening to mother's and newborns and what could we be doing about this? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Healthcare. Today we're going to talk about save motherhood, the scope of the problem. Today on The Scope.

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Dr. Kirtly Parker Jones: New reports on women and children show that the U.S. has increasing rates of death and complications due to pregnancy and childbirth especially compared to European countries. The U.S. is among just eight countries in the world to have an increase in maternal mortality, death during pregnancy, delivery, or in the six weeks after delivery. Of course many countries are doing better because they were doing so poorly ten years ago. When you're doing pretty well it's hard to do better, but we are doing worse.
It's very dangerous to be a mother in Somalia. The lifetime chance of a woman dying in childbirth is 1 in 7. Put another way, looking at how women die in Somalia, 1 in 7 die in complications relating to pregnancy. In Finland which is number 1 in the world as the safest place to get through pregnancies, the chance is 1 in 12,000. Somalia 1 in 7. Finland 1 in 12,000. In the U.S. the lifetime risk of dying in pregnancy was 1 in 3700 in 2000, and today it's 1 in 2400. That is 50% higher. Ten years later, 50% higher. That means a woman today is more likely to die from a pregnancy than she is from breast cancer.
So let's look at some reasons, there's been a dramatic increase in the rate of cesarean section in the U.S. Now 30% of babies are born by Cesarean Section, the third highest rate in the world. Having a baby by Cesarean increases the risk of hemorrhage and infection and pulmonary embolism, blood clot to the lungs. It increases the risk of problems in future pregnancies. It also affects the risk of newborn mortality but more about that later. You can see one of my previous blogs on decreasing the rate of cesareans.
More women are having babies later and they may not be in such great health, but that's not where the biggest increase in maternal mortality is noted. The biggest increase in the U.S. is in deaths in women 20 to 24. There are very large disparities in health outcomes in the U.S. compared to countries in the top performers for safety, that's Finland, Norway, Sweden, Iceland, Denmark, Switzerland, you know, those cold places. The U.S. has the largest income disparity in the industrialized nations and the most disparities in access to healthcare.
Now not all moms in the U.S. are getting equal treatment. In Scandinavia where healthcare is universal and almost everyone has access, moms fare very well. That's not the same in the U.S. What's really heartbreaking about being a mother in the U.S. is inequality. In the U.S., 18 mothers died for every 100,000 live births in 2013 which is double the rate of Saudi Arabia and Canada where 7 mothers died per 100,000 live births. The number more than triples for black women in urban America.
Now the rise in obesity in the U.S., in particular morbid obesity, increases the risk of dying in pregnancy, are greater risk of cesarean, greater risk of infection, greater risk of blood clots, and of diabetes.
Lastly but not leastly, at least to me, the U.S. has the highest rate of unplanned pregnancies in the industrialized world. Planning pregnancies gives mom a chance to get medical problems under control and seek healthcare. You can read my bit on cleaning out the incubator. So unplanned pregnancies and pregnancies that happen close together, less than 18 months apart, are more likely to have problems for the mom, and of course, low income women and women with little access to healthcare are more likely to have unplanned pregnancies.
What about the babies? We've made progress in newborn mortality in the past ten years but not much, not nearly as much as other countries. We haven't really made a dent in prematurity which is the biggest cause of newborn mortality. Repeat Cesareans, obesity, and unplanned pregnancy are all risk factors for prematurity and some of the same risk factors for maternal mortality.
We as women, as doctors and citizens have a responsibility to our most vulnerable member society, pregnant women and children. If we had the will, we do have the resources, and we could do more.
Number one, all women should space their babies, plan their pregnancies, make sure they're in good health prior to conception or under medical care, and seek prenatal care.
Number two, all OB/GYNs should take care in not delivering babies too soon unless there's a very good reason and should only do Cesarean Sections for very good reasons.
Number three, all healthcare systems should dictate good practices for deliveries and reach out to their most vulnerable moms.
Number four, the affordable care act had as a goal to get coverage for more women and mandates that insurance cover 100% of prenatal care, maternity care, and contraception, but there's been a lot of push back from industry and political groups. I hope that they're taking a long, hard look at our track record for maternal mortality. A lot of women still don't have healthcare. There is a white ribbon pin for safe motherhood. Check out the White Ribbon Alliance for safe motherhood. We should do better. We can do better.
This is Dr. Kirtly Jones, and thank you for joining us on The Scope.

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