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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."

Dr. Jones: So you ran out of your birth control pills and the condom broke or something like that. You really don't want to get pregnant right now or anytime soon. What do we know about your options?

Many women know about emergency contraception, and many don't, something you can do to decrease your chance of pregnancy if you had unprotected or under-protected intercourse. There are two types of emergency contraceptions approved by the FDA that are available in the U.S., and they are pills, and they decrease the chance of pregnancy if they're taken within five days of unprotected intercourse. But there are other types of birth control that would work and keep on working if you're looking for contraception for more than this month.

With us today is Dr. David Turok. He is an OB/GYN specialist in family planning and chief of the division of family planning at the University of Utah. Thanks for taking some time for us, Dr. Turok.

Dr. Turok: Thank you.

Dr. Jones: What were the background reasons to ask the question of whether the levonorgestrel IUD, which is what we're going to be talking about, would work for emergency contraception? What made you do this question?

Dr. Turok: Well, I speak with people a lot about emergency contraception because I'm very interested in it, and I think it's amazing that you can use something after you've had sex to prevent pregnancy. And every time I talk about it with people during grand rounds or during educational presentations, people always, always, always ask . . . because we know we have great data to say that the copper IUD works very well for emergency contraception, people always ask, "Well, what about the hormonal IUD, the levonorgestrel IUD? Can you use that?" So 10 years ago, we started trying to gather data on this topic, and finally we have an answer.

Dr. Jones: So people came to the clinic wanting emergency contraception and they walked into the clinic thinking that they might get some pills. How did you get so many women to participate in the study when they came for just pills?

Dr. Turok: Like in many aspects of life, Utah is unique. And currently, one of the forms of emergency contraception pills is available without a prescription. You can just walk into pharmacy or supermarket and get them. Sometimes it's behind the counter, you might have to ask, but you can get it without a prescription.

In Utah, because there are many limitations for people, young people especially, with insurance coverage, people seek out the cheapest place to get it, and that is Planned Parenthood where there's a sliding scale and where people have known for a long time that they can get the pills.

And we've done a few different surveys and a few different kinds of projects where we offer people walking in for emergency contraception IUDs, and it's around 12ish percent of people are interested in an IUD in that setting. And that's, I think, potentially driven in Utah by the fact that people don't have adequate insurance coverage and they're looking for opportunities to get better methods of contraception. And when there are low or no-cost options presented, people are interested.

So, at the peak before Plan B, one of the pills was available over the counter. Planned Parenthood statewide distributed more than 50,000 doses of oral emergency contraception. So people know, and lots of people come to Planned Parenthood clinics in our state for the service, and when you present them with IUDs, some are interested in it.

Dr. Jones: So some of them are really looking for something for longer than just this month?

Dr. Turok: Exactly. Yes.

Dr. Jones: Right. So you've known that the copper IUD . . . we've all known from data that goes back 20 years, really, that the copper IUD works. So you then offered them either a copper IUD or a hormone-containing IUD. And what did you discover?

Dr. Turok: So what we found in this study where we randomized people to get one or the other type of IUD, either copper or the hormonal IUD, we found that the pregnancy rate was low, very low, in both groups in the month after.

So with copper IUDs, we had 321 people who were assigned to that, and we got one-month outcome data on. And we expected in that group, zero or one would have a pregnancy. And it was zero.

And with the levonorgestrel group, we really didn't know. We had built into the study stopping points. Like, if there were a bunch of pregnancies early on, we were just going to stop. But what happened was there were 317 people who got the levonorgestrel IUD and there was one pregnancy. Lower than we thought and much better than the pills.

Dr. Jones: Right. That's important because the methods that are currently FDA-approved, that those 50,000 women who came to our clinics seeking pills, the failure rate or the ineffectiveness rate is much higher than what you found with the IUDs, either one of them.

Dr. Turok: Yeah. To me, one of the very cool things about the study is the other studies that got FDA approval for those oral methods, these were things that took a long time and hundreds of millions of dollars were spent to go through the FDA process to get that approval. And in this study, we took a method that was already FDA-approved and we just showed that it works for this as well.

And the upside relative to the pills is, as you know, that people who are getting this can get . . . this is not just better than the pills for this one event, but you can continue to use it as long as you want, up to seven years, or for the copper IUD, up to 12 years. And that is a set-it-and-forget-it method.

Then for the LNG IUD, there's this side benefit, which is why it's more popular than, I think, the copper IUD, in that it dramatically reduces or eliminates both menstrual bleeding and cramping. And that is a big upside. And that's why I think people really wanted an answer to this.

Dr. Jones: Well, we have some evidence from another big study that just gave women what they wanted when they asked for contraception and then followed them, that the IUDs were something like 20 times more effective than birth control pills in preventing pregnancy?

Dr. Turok: Correct.

Dr. Jones: So if a woman comes to our clinic for an emergency contraception and she wants long-term reliable contraception, would she be offered an IUD, do you think, in our clinics? Because now that the work was done around here, I'm hoping that our clinicians know that it's an option. Do you think it's going to be used in the clinics?

Dr. Turok: I want to say absolutely.

Dr. Jones: I do, too.

Dr. Turok: But I would also say as our team is working on getting this paper published, I would occasionally have these pangs of terrible thoughts that 10 years down the road, it's going to be like the authors of this paper and 10 other people that we know that know about this and nobody is going to ever have done any of it.

And so I started making lots of phone calls and sending lots of emails to people who I thought would be critical partners in disseminating the information. And one of the things that helps get the word out a lot is getting the paper published in a high-impact journal.

Dr. Jones: Right. It was published in "The New England Journal of Medicine," which is probably our premier medical research journal, I think, in the United States, or one of them.

Dr. Turok: One of the, I think, nice things about the study is "The New England Journal" publishes papers that change practice. That is their main motivator for selecting research articles. And you have a very low chance of submitting something and getting it published. But it was very reassuring to know that they felt this was important enough to be published there and that they were confident that it would change practice.

And there are lots of other organizations, professional organizations, a variety of health practitioners, and providers that can disseminate this to people who work with them.

I also have been working with the people from UpToDate to revise the article on emergency contraception to incorporate this and they were amazing. ACOG carried a piece on their listserv email and we're going to work with them to try to update Lark information in their emergency contraception information. So there are all kinds of ways to get the information out.

And a really important place to do that is also with Planned Parenthood Federation of America. As you know, they have something called the National Medical Committee that makes decisions on changes in practice. So I just sent an email and lately before this interview responding to questions from people who organize the National Medical Committee about this.

It's, I think, a great opportunity for Planned Parenthood Federation of America to lead on the dissemination of this because the information came exclusively from Planned Parenthood clinics. This is a collaboration between our team at the University of Utah and Planned Parenthood Association of Utah.

If you look at what gets published in "The New England Journal," the vast majority . . . and currently, probably nobody is a more fastidious reader and consumer of their publication than you. If you look at those trials that get published, most of them are these big, multi-site, and sometimes multinational studies with tons of sites and huge numbers of participants. This study is different.

Dr. Jones: It is. It's really amazing that you have a very local group who was completely committed to answering the question. And I think that that's a phenomenal thing.

I think, at The Scope, we're trying to get the word out also to individual women so they might be willing to come in and ask. So not only do clinicians need to know, but if individual women say, "By the way, do you think I could get this IUD today? Do I have to wait?" that changes practice.

Dr. Turok: Absolutely. So the education and dissemination of information have to be from push and pull factors from supply and demand side. And as I had mentioned, we're already working on trying to get providers up to speed. But there's lots of opportunity that we're going to be working on to make sure that people who are seeking emergency contraception will know about this.

Obviously, the internet is a fabulous place to do that. And there are also some organizations that focus specifically on emergency contraception. There's a U.S. Emergency Contraception Consortium and an International Consortium of Emergency Contraception, and they are fabulous at providing consumers information about different products and ways to access them. So we look forward to working with them as well.

Dr. Jones: Right. Well, Dr. Turok, I am very grateful for your time, and we'll work at The Scope in trying to get people the information they need. But the research to answer this kind of question takes years and takes a team of dozens of nurses, and clinic staff, and researchers, and above all, it takes hundreds of women who are willing to participate, answer questions, and follow up. To all of them, we are very grateful because "I hope I just didn't get pregnant" isn't a very good birth control method. And it's been a long time coming and I'm so glad to see it here. Thanks a lot, 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.