For pregnant women, a trip to the pregnancy-advice section of their local bookstore can be an overwhelming experience. The shelves are stacked high with suggestions and prohibitions for expectant mothers in a nine-month period when everything they do seems to matter. Using hair dye, drinking alcohol or coffee, gardening without gloves, or riding a bike are just a few no-nos on a long list. If women slip up, the consequences seem immense. “You’ve got nine months of meals and snacks with which to give your baby the best possible start in life,” the authors of What to Expect When You’re Expecting write. “Try to make them count. As you raise fork to mouth, consider: ‘Is this a bite that will benefit my baby?’”
The problem is, pregnancy-advice books often contradict each other. (Is fish a pregnancy superfood, or a mercury-laced toxin? Is peanut butter a delicious, protein-filled snack or a guarantee that your child will have peanut allergies?) Many aren’t written by experts—What to Expect When You’re Expecting, the so-called “pregnancy bible,” was authored by a mother-daughter team of a journalist, an advertising copywriter, and a nurse—and their recommendations can drift from the stridently proscriptive to the completely irrelevant. “If drinking two cups of coffee a day increases the likelihood of miscarriage, why would you mess with one?” demand the authors of Skinny Bitch: Bun in the Oven. “IT’S JUST NOT WORTH IT. GET OVER YOUR ADDICTION.” Another book, The Complete Organic Pregnancy, moves from advice about caffeine intake to a sales pitch for fair-trade coffee, telling mothers-to-be that if they must drink coffee, “try whenever possible to buy fair-trade, shade-grown, and/or organic."11 Fun fact: one of the authors is a former producer on Jimmy Kimmel Live.
Emily Oster, an associate professor of economics at the University of Chicago, was irritated to find herself catapulted into this “world of arbitrary rules” when she became pregnant in 2010. Doctors and books gave her “one-size-fits-all” recommendations that lacked her profession’s most valued currency: numbers. There is risk involved in almost everything pregnant women do, but her doctor was unable to quantify these perils using data, so that Oster could, as she did with most decisions, weigh the pluses and minuses using the best information possible. Oster decided she would write a corrective. In her new book, Expecting Better: Why the Conventional Pregnancy Wisdom is Wrong—And What You Really Need to Know, and on her new blog at Slate, she uses medical data to dismantle some of pregnancy-advice literature’s most-beloved myths. The book rejects wholesale prohibitions on drinking alcohol and coffee, taking Prozac, cleaning the cat’s litterbox, using hair dye, and eating fish, to name a few. Instead, Oster combs through medical studies, using her social-science training to evaluate the risks involved these actions. Her goal, she says, was to write a book for her friends: women who wanted data to bring to their doctors’ office and help them make informed, personalized decisions. “This book,” Oster writes, “is a way to take control and to expect better.”
In the week or so since it was released, the book has caught some flak. But it’s also been hailed as part of a wider movement that’s all about empowering women to think more critically about the advice they receive during pregnancy and childbirth. Oster positions herself as a trailblazer in criticizing obstetric and cultural approaches to prenatal care, but she has more company than she acknowledges; in fact, her background as an economist is the most novel part of her approach. Back in 2004, Michael S. Broder, an MD, wrote The Panic-Free Pregnancy, a book intended to help women weather a pregnancy with minimal stress. He says that the intent behind his book was similar to Oster’s. “Information about pregnancy is presented as black and white facts to most women,” he says. “My greatest fear is that it just makes people feel guilty when they don’t hew to this advice that isn’t very strong to begin with.”
Although the idea of an economist offering medical advice may seem ridiculous at first blush, Oster might be better equipped to analyze the medical data on pregnancy than most clinicians. “In medical school, you don’t learn how to sort out a good study from the bad study,” Broder explains. “You learn how to prevent a disaster and deal with a disaster when it’s facing you. Economics is all about sorting through the available information using proven methodologies and make the best sense you can of the information. It’s a more logical connection than you might think.”
In her book, Oster also speaks from the perspective of a pregnant woman, not just an economist. Amy Romano, a certified nurse-midwife, says it’s easy to forget that experts don’t have all the answers. “We hold medical professionals on a pedestal and forget that patients—people whose health is in the balance—have valid information to bring to clinical decision-making,” she says. “That’s what [Oster’s] doing. She’s a very informed, savvy healthcare consumer.”
Some doctors nevertheless object to the premise of Expecting Better, which is that pregnancy—much like childhood—is a time when women are expected to unquestioningly obey advice from authority figures that may not make sense. Obstetricians and nurse-midwives, they say, are increasingly trying to alter their practice to better support women. “Offering advice isn’t the same as keeping someone from doing something. It’s a conversation—not just me making rules and setting limits,” says Jeffrey Ecker, MD, an obstetrician at Massachusetts General Hospital. He adds that it’s hard for obstetricians to give definitive, numbers-based advice when the information isn’t always reliable. Their job, as he sees it, is to be honest about their level of concern.
Other doctors pointed out that quibbling over whether pregnant women can eat sushi overlooks more pressing medical concerns. Oster includes a slim chapter on planned labor induction, an issue that Catherine Ruhl, the director of Women’s Health Programs at the Association of Women’s Health, Obstetric, and Neonatal Nurses, says could make a much bigger difference to pregnant women than giving them the green light for raw fish. Planned induction—rather than allowing labor to start on its own—is increasingly routine, not because of medical necessity, but because of convenience. “Doctors will say to women, let’s plan an induction for your due date because that’s the day I’ll be in the hospital,” Ruhl explains. “But then women experience more pain during labor, they’re at a higher risk for cesarean sections, and they’re getting all these chemicals pumped into their bodies. It makes the sushi question seem like kind of small potatoes.”
Regardless, it is Oster’s assertion that pregnant women can have one to two drinks a week in the first trimester and up to one drink a day in the second and third trimesters that sent the Internet into a tizzy. The National Organization on Fetal Alcohol slammed the book in a press release, disparaging Oster’s lack of medical experience. In a blog post, the president of the American College of Obstetricians and Gynecologists, Jeanne A. Conry, also urged caution, but took a more diplomatic approach. Obstetricians, she wrote, shouldn’t encourage patients to use their own child as a test subject.
Wary reactions weren’t limited to doctors. In a blog post for The New York Times, KJ Dell’Antonia writes that she lost a baby to an infection caused by listeria bacteria, which can be caused by a wide range of foods, including deli meats and soft cheeses. Because it’s nearly impossible to avoid the full list of foods that have been associated with listeria outbreaks (everything from grilled chicken to cantaloupes), Oster opted to avoid queso fresco and turkey sandwiches. “Once you’ve been the unlucky number, the way you look at those numbers changes,” Dell’Antonia writes. “If I’d avoided all the most likely listeria carriers during that pregnancy, I might still have lost that baby. I probably still would have felt guilty. I just might have been able to direct a little more of my anger at fate, and less at myself.”
Inflexible or confusing advice from doctors and pregnancy advice books isn’t the only problem. For women in the United States, anxiety about pregnancy is in the water. “It used to be that we thought about bad outcomes around birth as a matter of fate, but now they’re a matter of fault,” says Elizabeth Mitchell Armstrong, an associate professor of sociology and public affairs at Princeton University. “If something goes wrong with your pregnancy, you’re going to be blamed by people around you, like your doctor or your mother-in-law or your partner. There’s a tremendous sense of personal responsibility, so women are very fearful about doing the wrong thing. There’s not a shred of evidence that moderate drinking affects [pregnancy] outcomes. Many would still rather abstain.”
Oster’s book is still a big step in the right direction—and a welcome addition to the shelf of pregnancy books. It’s hard to argue that putting more information in women’s hands is a bad thing, even for doctors who are apprehensive about some of Oster’s concerns. But it will take a lot more than a single economist to change the status quo. In some ways, Broder says, the intensity of the angst around the minutiae of pregnant women’s lives is a sign of how far maternal care has come. “There’s a saying that the safer things get, the more we worry about them,” he says. “Pregnancy is already so much safer than it used to be. Women dying in childbirth, poor prenatal care, infant mortality—that was very common not so long ago. Now we’re obsessed with little things, and they’re subtler and harder to understand. It’s more difficult to explain, and as frustrating as it may be, it’s not going to change overnight.”