Would you expect a physician to provide professional advice on what home to buy and mortgage to take? Should an economist give tips on whether pregnant women can eat sushi, drink wine or coffee or take certain drugs they have been told they must avoid? It would seem that such counsel is out of place and that specialists should stick to their own field of expertise.
Yet Prof. Emily Oster, who teaches introductory microeconomics to first-year master of business administration students at the University of Chicago, had the temerity to do so. When she wrote her book Expecting Better: Why The Conventional Pregnancy Wisdom Is Wrong and What You Really Need to Know, a couple of years ago after giving birth to her first child, Penelope, at around the age of 30, she was both praised and lambasted by critics.
Now her book has been translated into Hebrew as the NIS 99 paperback Harayon Berosh Aher (Schocken Publishing House). But this time it was run with a foreword and numerous comments on relevance to Israelis by Prof. Daniel Seidman, a senor gynecologist/obstetrician at the in-vitro fertilization unit at Sheba Medical Center in Tel-Hashomer and at Tel Aviv University’s Sackler School of Medicine, as well as co-director of the IVF Unit, Assuta Medical Center president of the Israel Society of Contraception and Sexual Health.
The two-and-a-half-page introduction by Seidman, who is described as the book’s “scientific editor,” is calming for readers of the Hebrew edition, as he agrees with much of what Oster writes and even more with the motivation behind her authoring of the book.
“Pregnancy is an experience of emotions and curiosity, an exciting and enjoyable chapter in life. But modern technology has turned it into an obstacle course in which one must pass successfully through a series of examinations… There are also many options, of a natural birth, being assisted by a doula, giving birth at home, having an epidural or not and so on.”
A cornucopia of Internet sites, Seidman continued, can give advice – some serious and some baseless – and have launched something of a “scare campaign. Don’t eat fresh fish; mayonnaise is dangerous; liver is poisonous; (certain) drugs are deadly – and many more prohibitions and warnings.”
Oster was “shocked” when first pregnant to discover the many limitations on women in her condition, and upon examining them using her critical skills as an academic, found they were not necessarily based on facts from comprehensive and thorough studies.
“She stresses throughout that her conclusions are right for her own pregnancy and personal preferences, and that every woman has to herself consider the benefits and shortcomings of different situations in pregnancy... Every woman must decide herself how important drinking alcohol while pregnant is to her. There are women who will feel comfortable eating sushi in a store she knows that sells fresh fish. Others will prefer to avoid it.”
The book is especially important to Israeli women, Seidman continues, because they are exposed to a lot of “grandmother’s tales” – advice that clashes with Health Ministry guidelines and instructions from their own doctors.
“I hope the new book will be an important tool to reduce anxieties that often accompany pregnancy and birth and ease decision making.
It is not meant to give ‘newer and better recommendations’ that will counter those of their own doctors but will encourage women to assess them with a critical eye and make informed choices.
“While every doctor would be glad to support smoking cessation and not drinking alcohol during pregnancy, exaggerated avoidance of many foods could result in a less-balanced and unhealthful diet.”
While avoiding uncontrolled taking of medications during pregnancy is wise, there is no reason for a woman to suffer from symptoms only due to anxiety about taking certain painkillers and pills that have been proven safe to treat nausea and vomiting. Failing to treat chronic vomiting is liable not only to cause the woman to suffer but also to lead to dehydration and a poor condition in pregnancy that can be much riskier than taking certain drugs, he continued.
There is no other country in the world besides Israel where pregnant women undergo so many tests, some of them unnecessary, said Seidman, thus Oster’s book will help them think more critically.
The book has been updated to cover genetic chips and other new technologies increasingly being used here.
“I believe that pregnant Israelis will find that the volume has relevant information that will make it possible for them to enjoy... it and internalize that one can have a relaxed and enjoyable pregnancy.”
OSTER WRITES that “in the fall of 2009, my husband, Jesse, and I decided to have a baby. We were both economics professors at the University of Chicago. We’d been together since my junior year of college, and married almost five years. Jesse was close to getting tenure, and my work was going pretty well. My 30th birthday was around the corner. I’ve always talked about having a family, and the discussion got steadily more serious. One morning in October we took a long run together and, finally, decided we were ready. Or, at the very least, we probably were not going to get any more ready. It took a bit of time, but about 18 months later our daughter, Penelope, arrived.”
She continued: “What I didn’t expect at all is how much I would put the tools of my job as an economist to use during my pregnancy.
This may seem odd. Despite the occasional use of “Dr.” in front of my name, I am not, in fact, a real doctor, let alone an obstetrician.
If you have a traditional view of economics, you’re probably thinking of Ben Bernanke making Fed policy, or the guys creating financial derivatives at Goldman Sachs.
You would not go to Alan Greenspan for pregnancy advice. But the tools of economics turn out to be enormously useful in evaluating the quality of information in any situation. Economists’ core decision- making principles are applicable everywhere. Everywhere. And that includes the womb.”
When she got pregnant, Oster recalled, “I pretty quickly learned that there is a lot of information out there about pregnancy, and a lot of recommendations. But neither the information nor the recommendations were all good.
The information was of varying quality, and the recommendations were often contradictory and occasionally infuriating. In the end, in an effort to get to the good information – to really figure out the truth – and to make the right decisions, I tackled the problem as I would any other, with economics.”
Pregnancy medical care seemed to be “one long list of rules. In fact, being pregnant was a lot like being a child again. There was always someone telling you what to do. It started right away.
“You can have only two cups of coffee a day.” I wondered why – what were the minuses (I knew the pluses – I love coffee!)? What did the numbers say about how risky this was? This wasn’t discussed anywhere.” Pregnancy seemed to be treated as a one-size-fits-all affair.
“The way I was used to making decisions – thinking about my personal preferences, combined with the data – was barely used at all.”
As to alcohol, Oster “figured out the way to think about the decision – there might be some decrease in child IQ from drinking (the minus), but I’d enjoy a glass of wine occasionally (the plus).
The truth was that the plus here is small, and if there was any demonstrated impact of occasional drinking on IQ, I’d abstain. But I did need the number: would having an occasional glass of wine impact my child’s IQ at all? If not, there was no reason not to have one.
“Or in prenatal testing. The minus seemed to be the risk of miscarriage.
The plus was information about the health of my baby. But what was the actual miscarriage risk? And how much information did these tests really provide relative to other, less risky, options?” However, her obstetrician did not offer scientifically based data on either of these issues. Oster did not interview physicians, but she did go to the Internet to search for recommendations from the American Congress of Obstetricians and Gynecologists.
“Interestingly, these recommendations were often different from what my doctor said – they seemed to be evolving faster with the current medical literature than actual practice was. But they still didn’t provide numbers.”
There has also been advice from psychologists and physicians to keep infants away from TV for the first two years of life. But, Oster argues that no harm has been proven.
“They base this recommendation on evidence provided by public health researchers (the same kinds of people who provide evidence about behavior during pregnancy).
Those researchers have shown time and again that children who watch a lot of TV before the age of two tend to perform worse in school.
“Imagine that I told you there are two families. In one family the one-year-old watches four hours of TV per day, and in the other the one-year-old watches none. Now I want you to tell me whether you think these families are similar. You probably don’t think so, and you’d be right.”
On the average, the kinds of parents who forbid television tend to have more education, be older, read more books, and on and on. So is it really the television that matters? Or is it all these other differences? This is the difference between correlation and causation… When you see a child who watches a lot of TV, on average you expect him to have lower test scores. But that is not causation.”
Oster also decries advice to get a lot of rest in bed when pregnant, as the data have backed this up, and today, many obstetricians no longer give this advice. She absolutely backs prohibitions against smoking even a single cigarette during pregnancy, saying that the medical evidence of tobacco’s harm to mother and fetus are incontrovertible.
Based on her handling of research results, she advises no eating raw or not-completely-cooked chicken or meat or unwashed fresh produce due to the risk of toxoplasmosis due to parasites; or of unpasteurized cheese and turkey pastrami (listeriosis, food poisoning caused by bacteria). She also nixes gardening because of the risk of toxoplasma, but she thinks cleaning your cat’s litter box is nothing to be worried about, nor – she argues on the basis of medical data – is sushi or eating raw eggs.
She digs into other pregnancy subjects, divided into the first, second and third trimesters, labor and delivery, epidurals and more. At the end of each chapter, she puts her recommendation in boxes titled “The Bottom Line.” At the back of the volume are 30 pages of bibliography.
MUCH CRITICISM of the book when it was originally published in English emanated from the US National Organization on Fetal Alcohol Syndrome and the American Congress of Obstetricians and Gynecologists, insisting that pregnant women should totally abstain from alcohol before giving birth.
They argued that physicians take an oath to “First do no harm.” That principle directs them even when they are not completely certain if something is safe or not. As it is not such a big deal to abstain from alcohol for nine months, they advise this to protect the baby and the mother in case it could, in each individual case, cause irreversible harm.
Oster’s book, the author sums up, “is decidedly not about recommendations.
It’s about information.
You can find plenty of books that tell you, “Go ahead, have a glass of wine.” I do say that, but I also explain why I came to that conclusion, with citations to the medical literature.”
Women who have no problem depriving themselves of certain things during pregnancy can go ahead and do that, while those who are skeptical and want to see the evidence can adopt Oster’s approach and speak to the obstetrician/gynecologist they trust before deciding.