Expecting Better: Why the Conventional Pregnancy Wisdom is Wrong—and What You Really Need to Know

Book Title: Expecting Better: Why the Conventional Pregnancy Wisdom is Wrong—and What You Really Need to Know

Book Author: Emily Oster

Publication Information: New York, Penguin Books, 2016, 313 pp., $17, paperback

As every clinician who takes care of pregnant women knows, expecting mothers have lots of questions, and often our answers are not necessarily data driven. Emily Oster is an economist at Brown University with an interest in medical economics. In Expecting Better, she attempts to ferret out fact from fiction and help the reader understand that some recommendations are not data driven, and to debunk the dogma of pregnancy—or at least explain its roots. In Dr Oster’s view, “The key to good decision-making is taking information, the data, and combining it with your own estimates of pluses and minuses.” 

The book is very accessible and practically organized. Broken down into five parts—conception, first, second, and third trimesters, and labor and delivery—it is written for pregnant women, designed to be picked up and put down as questions arise during pregnancy. The chapter titles often give a flavor of the discussion. For example: “Home Birth: Progressive or Regressive? And Who Cleans the Tub?” Dr Oster’s biases (for example, against home birth) are not hidden, and at the same time, she clearly makes an effort to present both sides fairly.

Oster makes great use of illustrative graphs, and her descriptions—for example, timing of ovulation, possible consequences of gestational diabetes, or how long the stages of labor are likely to be—are all very clear and accurate, designed for the lay person, but not dumbed down. This book will definitely appeal to many patients curious about what to expect and why to expect it.

The foundation of Dr Oster’s position is the idea that obstetrics suffers from a lack of good clinical studies and the “overinterpretation of flawed studies.” Very true. She points out the lack of randomized controlled trials after a very succinct explanation of what they are. She looks for the data behind the recommendations and exposes the absence of data in many cases. She refreshingly points out how the pendulum of expert opinion swings from one extreme to the other. While Dr Oster encourages readers to examine the data and come to their own conclusions, she also astonishes with some of her own conclusions. For example, in discussing alcohol consumption in pregnancy, she points out that recommendations vary in different countries. In particular, she objects to the phrase “no amount of alcohol has been proven safe,” concluding based on the lack of studies that perhaps “light drinking is fine.” While she may be right, many patients might not understand the gamble of fetal alcohol syndrome. Patients’ “estimates of the pluses and minuses” might not be balanced.

Overall, Dr Oster’s research is comprehensive, her descriptions are clear, and her arguments are well considered, yet they, like the data, are not definitive. Sometimes, as we know especially well in obstetrics, there is not a randomized controlled trial to definitively prove a point, and we must rely on the best available evidence and experience. To me, this naturally invites an opportunity for discussion. Dr Oster, however, misses the opportunity to direct the patient back to her clinician for what should be an important patient-centered discussion and decision-making process. This diminishes the book’s potential to be a great patient resource to being only a good one, and only in the hands of the right patient.