Expecting Better

Introduction

Pregnancy is a time filled with excitement, anticipation, and often, a fair amount of anxiety. For many expectant mothers, the barrage of advice, rules, and restrictions can be overwhelming. From avoiding certain foods to limiting caffeine intake, pregnant women are bombarded with a seemingly endless list of dos and don'ts. But how much of this conventional wisdom is based on solid scientific evidence, and how much is simply myth or outdated information?

In her groundbreaking book "Expecting Better," economist Emily Oster takes a fresh, data-driven approach to pregnancy. Drawing on her expertise in analyzing research and interpreting statistics, Oster challenges many long-held beliefs about pregnancy and offers a new perspective on making informed decisions during this crucial time.

As an expectant mother herself, Oster found that much of the advice she received was vague, contradictory, or lacking in scientific backing. Frustrated by the lack of clear, evidence-based information, she decided to apply her economic decision-making skills to the world of pregnancy. The result is a refreshing and empowering guide that encourages women to think critically about the choices they face during pregnancy and make decisions based on real data rather than fear or outdated conventions.

Throughout the book, Oster tackles a wide range of topics, from conception and prenatal testing to labor and delivery. She delves into the research behind common pregnancy recommendations, evaluating the quality of studies and presenting the information in a way that allows readers to weigh the risks and benefits for themselves.

This summary will explore the key insights and findings from "Expecting Better," providing a comprehensive overview of Oster's approach to pregnancy and the evidence-based conclusions she draws. By the end, you'll have a clearer understanding of how to navigate the often confusing world of pregnancy advice and make informed decisions that align with your own values and circumstances.

Applying Economic Decision-Making to Pregnancy

At the heart of Oster's approach is the application of economic decision-making principles to pregnancy. This framework involves two crucial elements:

1. Gathering high-quality data
2. Assessing the costs and benefits of each decision

Oster found that much of the information available to pregnant women was lacking in concrete numbers and reliable evidence. To address this, she went directly to the source: academic medical literature. By examining the original studies that formed the basis for many pregnancy recommendations, Oster was able to evaluate the quality of the research and extract meaningful data.

One of the key skills Oster brings to the table is her ability to interpret observational data. In pregnancy research, it's often unethical to conduct randomized trials, so researchers must rely on observational studies. Economists are well-versed in gleaning valuable insights from this type of data, and Oster applies this expertise to pregnancy research.

The second part of the decision-making framework involves weighing the costs and benefits of each choice. Oster emphasizes that this is a highly personal process, as different women will have different priorities and values. However, by providing clear information about potential risks and benefits, she empowers women to make decisions that align with their own preferences.

Throughout the book, Oster encourages readers to think critically and not simply accept conventional wisdom at face value. She provides the tools and information necessary for women to take control of their pregnancy experience and make choices based on evidence rather than fear or arbitrary rules.

Conception and Early Pregnancy

Oster begins by addressing common concerns and myths surrounding conception and the early stages of pregnancy. Here are some key findings:

Age and Fertility

Contrary to popular belief, fertility doesn't suddenly plummet at age 35. While it's true that fertility declines with age, the drop-off is gradual. Oster cites a study of 2,000 women trying to conceive, which found that 36% of those over 40 got pregnant within a year. This challenges the notion that women have a strict biological deadline for starting a family.

Timing Conception

Oster discusses three methods for determining ovulation:

1. Temperature charting
2. Cervical mucus analysis
3. Ovulation predictor kits ("pee sticks")

She found that ovulation predictor kits are the most accurate but also the most expensive. Temperature charting, while free, can be effective if done consistently. In a University of Naples study, 60% of women were able to pinpoint either the day of or the day before ovulation using this method.

Alcohol and Conception

Addressing concerns about alcohol consumption during the two-week wait between ovulation and a positive pregnancy test, Oster concludes that moderate drinking is unlikely to cause harm. Even a significant amount of alcohol won't do serious damage during fertilization, though heavy drinking could potentially prevent implantation.

First Trimester Concerns

Oster tackles several common worries and restrictions associated with the first trimester:

Miscarriage Risk

Rather than adhering to the common practice of waiting until 12 weeks to announce a pregnancy, Oster provides a more nuanced view of miscarriage risk. The chance of miscarriage gradually declines throughout pregnancy:

• 11% at 6 weeks
• 6% at 8 weeks
• 2% at 11 weeks

She also notes that miscarriage rates increase with age, from 4.4% for women under 20 to 19% for women at age 35.

Nausea and Morning Sickness

Oster points out that nausea can actually be a positive sign in early pregnancy. Studies have shown that women who experience nausea have a lower risk of miscarriage. For those suffering from severe morning sickness, Oster encourages seeking treatment, as there are safe options available, including ginger, vitamin B6, and prescription medications.

Food and Drink Restrictions

Oster challenges several common food and drink restrictions:

• Alcohol: Light drinking (1-2 drinks per week) during the first trimester doesn't appear to negatively impact the baby's IQ or behavior, nor does it increase miscarriage risk.
• Caffeine: Up to two 8-ounce cups of coffee per day is considered safe.
• Sushi and raw fish: The risks of foodborne illness from raw fish are not significantly higher for pregnant women than for the general population.
• Deli meats and soft cheeses: The risk of listeria from these foods is very low, and Oster argues that the benefits of their nutritional value may outweigh the minimal risk for many women.

Oster emphasizes the importance of avoiding toxoplasmosis by thoroughly washing fruits and vegetables, avoiding raw meat, and staying away from cat litter.

Prenatal Testing and Screening

One of the most significant decisions many pregnant women face is whether to undergo prenatal testing. Oster provides a comprehensive overview of the options available and the factors to consider when making this choice.

Prenatal Screening vs. Invasive Testing

Oster explains the difference between prenatal screening and invasive testing:

1. Prenatal screening: Non-invasive tests that estimate the risk of chromosomal abnormalities but are not 100% accurate.
2. Invasive testing: Procedures like amniocentesis and chorionic villus sampling (CVS) that provide definitive results but carry a small risk of miscarriage.

Advances in Prenatal Screening

Oster discusses the evolution of prenatal screening methods:

• Traditional screening: Combines blood tests and ultrasound measurements.
• Cell-free DNA testing: A newer, more accurate method that analyzes fetal DNA found in the mother's blood.

The cell-free DNA test has a very low false-negative rate, with only about 1 in 90,097 chance of an incorrect negative result for women aged 30-34.

Invasive Testing Considerations

For invasive testing, Oster provides the following information:

• Amniocentesis: Performed between 16-20 weeks of pregnancy.
• CVS: Performed earlier, between 10-12 weeks.
• Miscarriage risk: Approximately 1 in 800 for both procedures.

Oster notes that with the advent of cell-free DNA testing, CVS is performed less frequently, which may lead to some doctors being out of practice and potentially increasing the risk.

Making the Decision

Oster emphasizes that there's no one-size-fits-all answer when it comes to prenatal testing. She encourages women to consider their personal values, risk tolerance, and what they would do with the information obtained from testing. Some women may choose to forgo testing altogether and rely on age-based statistics for chromosomal abnormalities.

The Second Trimester

As the pregnancy progresses into the second trimester, Oster addresses several key topics:

Weight Gain

Oster challenges the often strict approach to pregnancy weight gain, noting that:

• Gaining too little weight is generally more concerning than gaining slightly more than recommended.
• A mother's weight gain affects the baby's weight, with low birth weight potentially leading to complications such as diabetes and lower cognitive skills.
• The main risk associated with higher-than-recommended weight gain is an increased chance of needing a C-section.

Exercise During Pregnancy

Oster finds that while women who exercise tend to have lower-risk pregnancies, this could be due to overall health rather than the exercise itself. She concludes that:

• There's no evidence that exercise during pregnancy is harmful.
• Prenatal yoga may have positive effects, though studies are limited.
• High-risk activities like skiing should be avoided due to the risk of falling.

Sleep

Addressing sleep issues during pregnancy, Oster notes:

• Sleep aids can be used in moderation, with Unisom being a common and safe choice.
• Occasional use of Ambien is considered safe, though long-term use may be associated with preterm birth and low birth weight.
• The advice to avoid sleeping on your back during pregnancy is largely impractical and not strongly supported by evidence.

Gender Determination

Oster discusses various methods for determining the baby's sex:

• Ultrasound or invasive testing at 20 weeks is highly accurate.
• New blood tests can determine sex at any point in pregnancy but are not 100% accurate.
• Old wives' tales, such as predicting gender based on the baby's heart rate, are not reliable.

The Third Trimester

As the pregnancy enters its final stage, Oster addresses several important topics and common concerns:

Premature Birth

Oster challenges some conventional wisdom regarding premature birth:

• Bed rest, often prescribed to prevent premature birth, lacks evidence of effectiveness and can lead to negative side effects like bone loss and muscle atrophy.
• Advances in medical technology have improved outcomes for premature babies, with survival possible for babies born as early as 22 weeks.
• Doctors can use drugs to delay birth for a few days if premature labor begins, allowing time for steroid treatment to speed up fetal lung development.

Predicting Labor

Oster provides insights into predicting the onset of labor:

• Cervical dilation is commonly used to estimate labor timeline, but cervical length (effacement) is actually a better predictor.
• Knowing these measurements can help with planning, such as arranging for family to arrive closer to the due date.

Labor Induction and C-sections

Oster discusses the increasing prevalence of labor induction and C-sections in the United States:

• Many inductions are done for scheduling convenience, but this often leads to C-sections.
• While C-sections can be life-saving in emergencies, they shouldn't be the first choice for most women.
• Induction is generally safe at full term but carries some risks if done earlier.

She also examines various induction methods:

• Nipple stimulation is a safe, at-home method proven to be effective.
• Membrane stripping, performed by a doctor or midwife, can also be effective.
• Some common reasons for induction, such as low amniotic fluid, lack strong supporting evidence.

Labor and Delivery

Oster provides a detailed breakdown of the labor and delivery process, challenging some common misconceptions and offering evidence-based insights:

Stages of Labor

1. First Stage (Dilation and Active Labor):

   • Can take days or even weeks
   • Contrary to popular belief, cervical dilation of 1-2 cm per hour is average, not slow
   • Only about 10% of women experience their water breaking before labor begins

2. Second Stage (Pushing):

   • Can last from a few minutes to a few hours
   • Ends with the birth of the baby

3. Third Stage (Placenta Delivery):

   • Occurs immediately after the baby is born
   • Can be surprisingly painful but is usually quick

Interventions During Labor

Oster discusses various interventions that may occur during labor:

• Breaking the water: Can be done to speed up slow labor
• Pitocin: Used to induce or augment labor
• C-section: May be considered in cases of previous C-section or breech presentation

Pain Management

Oster examines the pros and cons of pain medication during labor:

• Epidurals are common but can complicate the birth process by limiting movement and potentially affecting the baby's position
• Natural pain management techniques can be effective for some women

Birth Plans and Doulas

Oster emphasizes the importance of creating a birth plan and considering hiring a doula:

• Birth plans allow for discussion of preferences with healthcare providers in advance
• Doulas can advocate for the mother and have been shown to improve birth outcomes, including lower rates of C-sections and shorter labor times

Home Birth

Oster presents a balanced view of home birth:

• Pros include a more comfortable environment and less pressure for interventions
• The main risk is the potential need for emergency medical care
• Overall, the risk of complications during home birth is low for low-risk pregnancies

Making Informed Decisions

Throughout "Expecting Better," Oster emphasizes the importance of making informed decisions based on high-quality evidence rather than fear or outdated conventions. She provides readers with the tools to evaluate research and weigh the risks and benefits of various choices according to their own values and circumstances.

Key takeaways from Oster's approach include:

1. Question conventional wisdom: Many pregnancy "rules" are based on outdated information or overly cautious interpretations of data.

2. Evaluate the quality of research: Not all studies are created equal. Look for large, well-designed studies and be wary of small sample sizes or poorly controlled variables.

3. Consider personal preferences: What's right for one woman may not be right for another. Factor in your own values, risk tolerance, and lifestyle when making decisions.

4. Seek out concrete numbers: Vague terms like "risky" or "probably fine" aren't helpful. Look for specific statistics to better understand the actual likelihood of various outcomes.

5. Balance risks and benefits: Few choices in pregnancy are risk-free, but the potential benefits may outweigh small risks in many cases.

6. Communicate with healthcare providers: Don't be afraid to ask questions and discuss your preferences with your doctor or midwife.

7. Stay flexible: New information may emerge during your pregnancy, and your circumstances may change. Be prepared to reassess your decisions as needed.

Conclusion

"Expecting Better" offers a refreshing and empowering approach to pregnancy, challenging many long-held beliefs and encouraging women to take an active role in their prenatal care. By applying economic decision-making principles to pregnancy, Emily Oster provides a framework for navigating the often confusing and contradictory world of pregnancy advice.

The book's strength lies in its ability to present complex medical information in an accessible way, allowing readers to understand the evidence behind various recommendations and make informed choices. Oster's approach doesn't dictate what women should do, but rather equips them with the tools to make decisions that align with their own values and circumstances.

Some key takeaways from the book include:

1. Many common pregnancy restrictions, such as avoiding caffeine or sushi, are based on overly cautious interpretations of limited data.

2. Light drinking during pregnancy, particularly after the first trimester, is unlikely to cause harm to the baby.

3. Prenatal testing decisions should be based on individual preferences and risk tolerance, not arbitrary age cutoffs.

4. Exercise during pregnancy is generally safe and beneficial, with few restrictions necessary for most women.

5. Many interventions during labor and delivery, such as continuous fetal monitoring and routine episiotomies, lack strong evidence of benefit and may lead to unnecessary C-sections.

6. Creating a birth plan and considering hiring a doula can lead to better birth experiences and outcomes.

While Oster's conclusions may sometimes diverge from standard medical advice, her approach encourages women to think critically and engage more deeply with their prenatal care. It's important to note that Oster is an economist, not a medical professional, and her interpretations should be considered alongside advice from healthcare providers.

Ultimately, "Expecting Better" serves as a valuable resource for expectant parents, providing a data-driven perspective on pregnancy that can help alleviate anxiety and empower women to make confident, informed decisions. By challenging the status quo and encouraging a more nuanced understanding of pregnancy-related research, Oster has created a guide that can transform the way women approach this important life stage.

As pregnancy and childbirth research continues to evolve, the principles outlined in "Expecting Better" – critical thinking, evidence-based decision-making, and personalized risk assessment – remain valuable tools for navigating the complex world of parenthood. Whether you're currently expecting, planning for a future pregnancy, or simply interested in a fresh perspective on prenatal care, Oster's book offers insights that can benefit anyone involved in the journey of bringing new life into the world.