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Parenting25 min read
Expecting Better
by Emily Oster
Why the Conventional Pregnancy Wisdom is Wrong and What You Really Need to Know
Published: April 21, 2020
3.9 (114 ratings)
Table of Contents
1
what’s in it for me? practical and pragmatic guidance through the labyrinth of pregnancy.2
using the basic tools of economic decision theory, you can make informed choices about your pregnancy.3
reviewing the research paves the way for a smooth pregnancy.4
the first trimester of pregnancy comes with lots of big decisions – and some fears.5
a good decision framework is vital when it comes to decisions about prenatal testing.6
the second trimester brings various decisions, including whether or not to find out the sex of your child.7
in the third trimester, it’s time to tackle any big problems and make decisions about delivery.8
know the detailed timeline of labor before you arrive in the delivery room.9
when it comes to preferences during labor and delivery, one size doesn’t fit all.10
final summaryBook Summary
This is a comprehensive summary of “Expecting Better” by Emily Oster. The book explores why the conventional pregnancy wisdom is wrong and what you really need to know.
what’s in it for me? practical and pragmatic guidance through the labyrinth of pregnancy.#
Introduction
emily oster, expecting better why the conventional pregnancy wisdom is wrong and what you really need to know
if you're pregnant or planning a pregnancy, it's easy to be overwhelmed by all the restrictions and guidelines.
maybe you've been told to cut out coffee and cold cuts, but you have no idea why.
maybe your doctor scolds you every time you gain a bit more weight than is recommended for pregnant women, and you're paranoid about how it's going to affect the baby.
during her own pregnancy, the author, emily oster, found that women are usually given a list of accepted rules to abide by without any explanation or scientific evidence.
so she decided to evaluate the data, an endeavour made considerably easier by her experience as a leading economist.
in the end, she discovered that, more often than not, these rules were either misguided or downright wrong.
these chapters unveil oster's discoveries, debunking myths and untangling the more convoluted aspects of pregnancy from conception to gestation to labour.
using the basic tools of economic decision theory, you can make informed choices about your pregnancy.#
chapter number one using the basic tools of economic decision theory, you can make informed choices about your pregnancy.
when leading economist emily oster got pregnant, she found that every decision came with a strict set of do's and don'ts.
she was wary of believing recommendations or opinions that weren't supported by reliable evidence.
but much of the available information was flawed or contradictory.
her doctor also tended to offer edicts instead of answers.
when oster asked her obstetrician about certain medical or lifestyle choices, she expected to receive an outline of potential risks and benefits, along with supporting evidence.
instead, there were rigid guidelines.
amniocentesis is only for women over 35, or pregnant women should quit drinking coffee entirely.
oster wondered how many of these guidelines were simply arbitrary social norms perpetuated by misinformation.
so she put her economic decision-making principles to use and waded into the world of prenatal medical care.
an economist's framework for making decisions requires two things.
the first is good data, which was lacking in most pregnancy books and articles.
for example, having one or two drinks per week was probably fine, and prenatal testing was risky.
but what did probably fine and risky mean numerically?
for concrete numbers, she had to go directly to the source, the academic medical literature that the official recommendations were based on.
pregnancy research ran the gamut, from high-quality studies and trials to low-quality ones, and oster was well-trained in differentiating between the two.
because economists don't always have access to randomised trials, the gold standard for research, they tend to be experts in gleaning information from observational data.
studying pregnant women and alcohol, for example, a researcher couldn't ethically require subjects to drink.
she could glean observational data from women who do it anyway, though.
applying this skill to pregnancy research, oster found that many recommendations were based on not just flawed studies, but on overly cautious interpretations of those studies.
the second element of an economist's framework is an assessment of the costs and benefits of a decision.
of course, this is a highly personalised matter, especially when it comes to pregnancy.
after all, different women have different preferences and value different things, but it's nonetheless helpful to have a clear idea of what a decision's costs and benefits might be.
with that information, women can make smart decisions instead of blindly following recommendations.
in the following chapters, you'll find the conclusions oster came to after unearthing research on the many aspects of pregnancy.
some of her findings support conventional wisdom, others challenge or outright disprove it.
the evidence won't make your decisions for you, but it will help you to take control, think critically and make your own informed choices.
reviewing the research paves the way for a smooth pregnancy.#
chapter number two.
reviewing the research paves the way for a smooth pregnancy.
if you're trying to get pregnant, you probably have plenty of questions.
how old is too old to get pregnant?
does taking birth control pills affect fertility?
there are lots of things to consider while planning your pregnancy, and there are others that you shouldn't be too worried about.
age, for example.
are your eggs really best used by 35, as one paper offensively phrased it?
not at all.
it's true that fertility declines with age, dropping off precipitously after you turn 40.
however, in a study of 2,000 women trying to conceive, 36% of those over 40 got pregnant within a year.
what about physical condition?
do you need to be in tip-top shape for a healthy pregnancy?
well, while obesity is associated with a higher risk of complications for both mother and child, a few extra pounds won't make a difference.
when it comes to conception, one important factor is timing.
you can get pregnant up to five days prior to ovulation, but it's easiest to conceive either while you're ovulating or a day before.
there are three methods for figuring out when you're ovulating.
temperature charting, testing cervical mucus, and as the author calls them, p-sticks.
p-sticks are the most accurate, but at about $40 per month, they're costly.
temperature charting is free and pretty simple.
all you've got to do is take your temperature every day at the same time.
ovulation can be detected because for two weeks afterward, your body temperature will be higher than normal.
in a university of naples study from the 1990s, 60% of the women who participated were able to pinpoint either the day of or the day before ovulation using temperature charting.
the other option is analyzing your cervical mucus.
before ovulation, it'll be clear and stretchy like egg whites.
collect it by inserting a finger into your vagina and running it around your cervix.
according to the university of naples study, this method is almost 50% accurate at detecting the day of ovulation.
let's say you've done everything right.
you've pinpointed the day of ovulation and on that day, you had intercourse.
are you pregnant?
well, you might be.
so should you abstain from alcohol during that two-week wait before you can be absolutely sure?
the quick answer, no.
even a flight of whiskey won't do serious damage during fertilization.
yes, heavy drinking can kill the cells that are developing into your baby, but other cells will replace them.
that said, if you kill too many cells, the embryo won't develop and you won't become pregnant at all.
the first trimester of pregnancy comes with lots of big decisions – and some fears.#
chapter number three.
the first trimester of pregnancy comes with lots of big decisions and some fears.
if you're anything like most women, you'll spend at least part of your first trimester concerned about miscarriage.
it's scary.
so if someone tells you to avoid certain things during pregnancy, it's better to be safe than sorry, right?
not necessarily.
for example, despite popular opinion, alcohol, coffee and sushi don't need to be purged from your diet.
light drinking, one or two drinks per week during your first trimester, won't negatively impact your baby's iq or behavior, nor will it increase the likelihood of miscarriage.
as for caffeine, all evidence says two 8-ounce cups of coffee a day won't harm the baby.
when it comes to food, don't worry too much about raw eggs and raw fish.
bacteria like salmonella and e. coli don't pose any special risk to pregnant women.
avoid toxoplasmosis by cutting out raw meat, washing fruit and vegetables, and not gardening or handling cat litter.
there is a concern that the mercury content in fish can affect your child's iq, but fish is also rich in omega-3 fatty acids, which boost your child's iq.
choose fish with high omega-3s and low mercury, like salmon and sardines.
avoid canned tuna.
these lifestyle changes can help minimize the risk of miscarriage, and knowing the actual statistical risks can help give you peace of mind.
most people wait until the 12th week to share pregnancy news for fear of miscarriage, but biology isn't that punctual.
rather than dropping off suddenly at 12 weeks, the chance of a miscarriage gradually declines throughout pregnancy.
at 6 weeks, there's an 11% chance.
at 8 weeks, it drops to 6%.
by 11 weeks, it's just 2%.
rates of miscarriage also increase with age.
on average, 4.4% of women under 20 miscarry.
but by the time you're 35, that rate shoots up to 19%.
in vitro fertilization and previous miscarriage also increase your risk.
one sign of a healthy pregnancy is nausea.
30% of women who had first trimester miscarriages didn't experience nausea.
most are nauseated between 6 and 14 weeks, vomiting only for a few days.
if you're part of the 5% of women with severe nausea, don't suffer in silence.
there are many safe treatment options, from taking ginger or vitamin b6 to anti-nausea drug unisom, or stronger prescription drugs like zofran.
a good decision framework is vital when it comes to decisions about prenatal testing.#
chapter number 4.
a good decision framework is vital when it comes to decisions about prenatal testing.
to prenatal test or not to prenatal test?
and if so, how?
this is one of the more emotionally fraught decisions for many pregnant women, and there's no right answer.
what exactly is it, though?
well, prenatal testing detects chromosomal abnormalities such as down syndrome.
there are two testing methods, prenatal screening and invasive testing.
they're not mutually exclusive.
if you start with prenatal screening, you can always decide later whether or not to proceed with invasive testing.
the first thing to understand about prenatal screening is that it isn't 100% accurate.
think of it like shopping for fruit.
you can more or less judge a fruit's ripeness by its appearance, but there's always a risk you'll get it wrong.
perfectly ripe fruit sometimes get passed over just because of the way it looks.
similarly, doctors look for established features of healthy babies, but false negatives, when everything looks good but it's not, and false positives, when something looks irregular but it isn't, are possible.
prenatal screening used to mean combining blood tests to check hormone levels with an ultrasound.
there's a newer method, however, that's slightly more accurate, analysing cell-free dna, that is, dna that exists outside of cells.
during pregnancy, a mother's blood contains a small amount of her baby's cell-free dna.
by analysing it, doctors can flag chromosomal irregularities with great accuracy.
the risk of an incorrect negative test, in fact, is just 1 in 90,097 for women aged 30 to 34.
invasive testing, on the other hand, is 100% accurate but carries a small risk of miscarriage.
the chance is about 1 in 800.
there are two types of invasive procedures, amniocentesis and chorionic villus sampling, or cvs.
amniocentesis has been around for decades.
doctors perform it by taking a sample of a baby's cells from the amniotic sac, somewhere between the 16th and 20th week of pregnancy.
in cvs, the sample is taken from the uterus between 10 and 12 weeks.
cvs is the newer of the two procedures, but since the advent of cell-free dna testing, it's not performed as often.
as some doctors are likely to be out of practice, it can be riskier.
you could also skip the medical intervention, consider the statistical chance of your child having chromosome abnormalities given your age, and just wait and see when the baby is born.
the second trimester brings various decisions, including whether or not to find out the sex of your child.#
chapter number 5.
the second trimester brings various decisions, including whether or not to find out the sex of your child.
each stage of pregnancy carries its own unique characteristics and concerns.
in the first trimester, you're adjusting to a change in lifestyle.
in the second, you're in the thick of it, and things like exercise and healthy eating are especially important.
too many doctors go overboard when looking at weight gain, though, scolding their patients if they're even just a few pounds over the recommended weight.
in reality, unless you've gained a lot more than the recommended amount of weight, it's a much bigger concern to have gained too little.
a mother's weight gain affects her baby's weight, and babies who are small for gestational age face an elevated risk of complications, such as diabetes and lower cognitive skills.
the most significant complication for large for gestational age babies, by contrast, is the increased chance of needing a c-section.
watching your weight can be a challenge, of course, and it doesn't help that exercise and sleep can also be challenging during pregnancy.
on average, women who exercise have lower-risk pregnancies, but that doesn't prove much.
it could just be because they were healthier to begin with.
prenatal yoga seems to have positive effects, but the available studies are small.
on the other hand, there's also no reason not to exercise.
only avoid sports such as skiing where falling is possible.
a fall could cause your baby's placenta to detach, a major complication.
when it comes to sleep, aids can be helpful in moderation and there are safe options.
unisom is most commonly used, though it doesn't work for everybody.
occasionally, ambien use is safe, but one taiwanese study suggested that long-term ambien prescriptions during pregnancy could cause preterm and low birth weight babies.
women are often told not to sleep on their backs during pregnancy for fear of reducing blood flow to the placenta and the baby, but the majority of evidence suggests this is impractical.
another feature of the second trimester is deciding whether or not to learn the gender of your baby.
at 20 weeks, you can find out via ultrasound or invasive testing.
progress has also been made recently at determining sex via blood sample, which can be done at any point in pregnancy, but it's not 100% accurate.
old wives' tales aren't accurate either.
your aunt may insist that baby girls have faster heart rates, but she's mistaken.
if you prefer not to test for gender, you'll just have to wait and see.
in the third trimester, it’s time to tackle any big problems and make decisions about delivery.#
chapter number six.
in the third trimester, it's time to tackle any big problems and make decisions about delivery.
in your third trimester, the risk of complications is the highest at any point in your pregnancy.
that makes it more crucial than ever to arm yourself with solid information.
there's no better way to face your worries.
one of the biggest of these is premature birth.
many doctors recommend bed rest as a way to avoid this, but there's no evidence that it actually works.
nor is it worth risking bone loss and muscle atrophy, two common side effects.
the good news is that premature birth isn't as great a risk as it used to be.
advances in technology mean that babies born up to 22 weeks early have a chance of surviving outside the womb.
from 22 weeks onward, chances of survival increase dramatically.
plus, if you do go into labour early, a doctor can delay birth for a few days with drugs.
that gives you time to receive steroid treatment, which speeds up fetal lung development, and cervical checks can help predict the timeline of labour.
your doctor will probably tell you how dilated your cervix is.
right before labour, it opens to 10 centimetres.
knowing this number can help predict labour onset, but cervical length, called effacement, has more predictive power.
ask your doctor about it.
when the author's friend heather learned at 37 weeks that she was 1 centimetre dilated and 80% effaced, she moved her mother's flight up 10 days.
perfect timing.
her baby arrived just three days after her mother.
labour induction and caesarean sections have become increasingly common in the united states due to scheduling convenience, and because induction often leads to c-section.
though a c-section is good in an emergency, it shouldn't be your first choice.
induction is safe at full term.
earlier it carries some risks.
there are also some less reliable practices around inductions.
doctors sometimes induce because your uterus's amniotic fluid is low.
however, little evidence supports the need.
the effectiveness of induction methods varies a lot, too, but one safe at-home method that has been proven effective is nipple stimulation.
membrane stripping, a procedure in which a doctor or midwife uses a gloved finger to separate the amniotic sac from the wall of the uterus at the cervix, is also effective.
know the detailed timeline of labor before you arrive in the delivery room.#
chapter number 7.
know the detailed timeline of labour before you arrive in the delivery room.
the timeline of labour is usually presented vaguely with something like could be a few hours, could be a whole day.
but there are three distinct stages to labour, each with its own potential complications.
stage 1 has two parts, dilation and active labour, and it can take days or even weeks.
it's commonly believed that the absolute slowest your cervix should dilate is at a rate of 1 cm per hour, but a 2002 study of 1,300 women in hawaii suggests that 1 to 2 cm per hour is actually the average.
still, if your cervix dilates very slowly, your doctor may intervene by giving you pitocin, which induces labour or delivering the baby via c-section if it's in distress.
that's not the only misconception associated with the first stage of labour.
those dramatic scenes you see on tv where the woman's water breaks and she goes into labour right away?
well, only 10% of women experience this.
most have already started labour by the time their water breaks.
that said, if your water breaks before contractions start and you're still not in labour within 12 hours, induction may be necessary.
if active labour is going very slowly, your doctor can intervene by breaking your water, if it hasn't broken already, and then give you pitocin.
the second stage of labour is pushing, which can be anywhere from a few minutes to a few hours.
it ends when the baby arrives.
another common labour problem is trouble pushing the baby out, often because of the baby's position.
even if you intended to have a vaginal delivery, there are two situations where c-section could be an option to consider.
one is if you've had one before.
some studies show there are increased risks with a vbac, vaginal birth after cesarean.
so consider opting for another c-section from the get-go.
another is breach, when the baby is positioned to come out feet first.
in half of all breach cases, the doctor can move the baby manually by pushing from the outside.
the third stage is the placenta delivery, when the placenta is removed immediately after the baby.
it can be surprisingly painful, but it's quick.
after labour, you may decide to delay the clamping of the umbilical cord.
this is an easy way to get extra blood to preterm babies, who are at risk of anemia and other complications.
when it comes to preferences during labor and delivery, one size doesn’t fit all.#
chapter number eight.
when it comes to preferences during labour and delivery, one size doesn't fit all.
as you research birth practices, you might notice a stark divide between women who want medical intervention when they give birth and those who don't.
there is a middle path, though.
consider paying medication.
most women in the united states opt for it, but it can complicate the birth process.
for instance, an epidural, which is usually administered during the first stage of labour, numbs the lower half of your body.
it can't harm the baby, but because you can't feel anything or move around much, the baby might not get into the right position.
even if you'd prefer to go without pharmaceuticals, you might want to consider pitocin, which decreases your risk of postpartum hemorrhage, a common delivery complication.
if you should hemorrhage, it will stop blood loss.
whatever your decision, though, consider creating a birth plan.
writing down your decisions gives you time to discuss them with your doctor in advance.
eating and drinking, for example, often aren't allowed in the delivery room, though they're not dangerous during labour.
ask about your doctor's policy.
it's also important to discuss things you want to avoid.
for example, it's good to be explicit about episiotomies, a procedure in which the doctor cuts an incision in the area between your vagina and anus.
while this was a common procedure 40 years ago, there's strong evidence that the procedure can be harmful.
the best decision in the author's birth plan was hiring a doula, a childbirth specialist who advocates for the mother.
randomised trials, one from 2008 and another from 1991, have suggested that doulas have a significant impact on birth outcomes.
women with doulas are half as likely to have a c-section, half as likely to use an epidural and have shorter labour.
finally, is home birth for you?
there are many pros to delivering your child at home.
you don't have to rush to the hospital and wait in triage, no one cajoles you into things you don't want, like pain medication or c-section, and recovery is easier.
there is a risk that things will go wrong and you won't be able to get to the hospital in time, but that risk is very low.
once you've done your research and made enlightened decisions based on it, you can relax and enjoy your pregnancy.
after your baby is born, the real decision-making starts.
you've just listened to our chapters to expecting better by emily oster.
final summary#
Conclusion
the key message here is to make sure you have all the facts as you consider the pros and cons of each pregnancy decision.
certain things aren't as dangerous as you think, and some standard practices are actually not the safest.
conventional wisdom isn't tailored to individual people and scenarios, and not all scientific research is high quality, so stay inquisitive.
and here's one more bit of actionable advice.
research smart.
if you're weighing the costs and benefits of a decision by looking up studies, keep correlation and causation in mind.
for example, when a kid who watches too much television receives low test scores, that's correlation.
but it's not proof that television is making him dumber, because other factors need to be considered.
for instance, are his parents and home environment contributing to his excessive tv watching?
if so, that's causation.
these are important distinctions in evaluating the quality of a scientific trial.
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