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Author Emily Oster's new book 'Unexpected' tackles difficult pregnancies


Emily Oster made a name for herself using data to tackle big questions about pregnancy in her book "Expecting Better." The Brown University economist sifted through study after study to help guide readers through everything from the safety of sushi to whether it's OK to garden. Oster has taken the same approach to help parents better understand the early infant and toddler years, and the frantic craze of managing a household with school-age kids. But now, Oster is returning to her first topic with a book especially focused on how to navigate difficult pregnancies and serious medical issues. It's called "The Unexpected: Navigating Pregnancy During And After Complications," co-written with Dr. Nathan Fox, who specializes in high-risk obstetrics.

Emily Oster, welcome to ALL THINGS CONSIDERED.

EMILY OSTER: Thank you so much for having me. It's great to be here.

DETROW: You know, early on, you write, what is different about this book is that I hope you do not have to read it. It is odd to write a book that you hope people will not read. Why did you focus on this particular topic?

OSTER: In the decade or so since "Expecting Better" has come out, I have talked to thousands of women about pregnancy, and a lot of those conversations are about, I had this complication during pregnancy. I'm scared. I'm anxious. I want to understand it better. I want to understand what to do next time. And we did a survey of people just asking, you know, tell us about your pregnancy complications. And I think I have 4,000 responses, many of which are paragraphs and paragraphs long.

That helped us with the question of where to look in the data. You know, what were the questions people had most about the data? But it also helped us think about what I think is the other value of this book, which is to help people feel a little bit less alone. A lot of these complications we don't talk about very much, and when people have them, they feel that they're the only one. And of course, they're not. Actually, about 50% of pregnancies will involve or end in one of the complications we talk about in the book.

DETROW: Yeah. I want to talk about something early on that you write about that a lot of people experience, and it gets to that idea of feeling alone that you just mentioned. This is a chapter on early miscarriages and the big question of whether or not you should share that information with friends or family. And, you know, this is so much more about emotions than data, but how do you think about that? How do you approach that? And I'm wondering, has your view on when and how to share that information changed over the years?

OSTER: The traditional approach to this is that you share information about pregnancy around 12 weeks. That's a point at which the risk of miscarriage is lower. You're out of the first trimester. It's also - happens to be the point at which most people are starting to show. So it becomes more difficult to hide. Over the last several years - and people have gotten more comfortable with sharing this earlier - I don't think that it's something that you could give people advice on because the question is really, what is the support you're going to want if you did have a miscarriage?

And for some people, they aren't going to want to talk to other people. And grieving privately or with close family is what they want. For other people, that kind of broader support is going to be very valuable. The way we try to frame in the book is partly sort of thinking about the data and thinking about the risk of this by week so people get a sense of where these rates are by week. And then we also try to help people think about, if this does happen, what's the likelihood that it will happen again? How should you process that, and what are some things you can ask your provider? So that's the approach that we hope people will take.

DETROW: When you're thinking about complications and challenges that come up early on in pregnancy, how does the post-Dobbs landscape complicate all of this when you're taking a big-picture view of medical care in this country?

OSTER: Any time that we restrict access to medical care around women's health, it is going to have knock-on consequences that we may not have anticipated. So in the particular case of Dobbs and these pregnancy complications, there are a number of complications, most notably second trimester miscarriage, where the care that people would get in that circumstance is very, very overlapping with the care that would be part of abortion care.

And when providers have left a state or a locality because of these restrictions, that then limits the care that women can get in situations where they have lost a baby for some other reason. So it feels to me like very much just as we remove choice, we remove access. And access is something that is incredibly valuable for many, many reasons.

DETROW: Yeah. Can you talk about some of the other complications that you focus on in the book, some of the more common ones that a lot of people are going to be dealing with, one way or another?

OSTER: Yeah. So one of the more common complications is preterm birth. That's about 12% of the births in the U.S. And so there are many people who have experienced pre-term birth at varying times, and we talk about in the book is kind of how much does it matter when the preterm birth is? And then is that likely to happen again? And how much correlation is there across births?

There are also a lot of things which are probably more common than people expect, like vaginal trauma or prolapse experiences that women can have after birth, that are affecting how they feel, that are affecting their reproductive health, which are often not talked about because they are really about your sort of experience of the world as opposed to about mortality, which we're much better at measuring.

DETROW: And, you know, this book particularly focuses on second or third, you know, even fourth pregnancies. And if you experience a complication like this the first time around, the question of whether or not to have another child can be pretty fraught. And so much of this book deals with coming up with a plan, tips on how to be your own advocate, understanding your options, even coming up with a script of how you're going to talk to a doctor about this. Why to you is that so important?

OSTER: I think in order to feel engaged with your own care here, people need to have enough information to have a thoughtful conversation with their doctor. They need to have enough scripting to understand how to use the 15 minutes that they have to get the answers to the questions that are going to matter for their decisions. That's different from saying people need to be an expert. The doctor is an expert in the medical side. The person can be an expert in their own preferences and their own values. But in order for the conversation to be productive, they need to know enough to make it productive.

DETROW: Do you think doctors generally appreciate a patient coming in with their own game plan like that for the conversation, or do you think that sometimes there's a risk of putting off a doctor who sees themselves as the expert?

OSTER: So I think what is hard is to come in and say, I've decided to do X because I think for many doctors, the answer is like, well, you're not a good candidate for that, you know, for this medical reason that I could explain to you. I think the approach of I've come in with a set of, of conversation topics, a set of things that I think we need to work through together, it's harder for me to see how someone would object to that.

So I think there's a - there's really a balance. And this is part of why it was so valuable to write this together with Nate, so we could think about what would he want on his side from his patients and what would I want as, yes, an expert in data but also a patient myself. How could we bring those together in a way that we would have the relationship we were both want?

DETROW: I wanted to tie this back to "Expecting Better," and it's been more than a decade since that book came out. What is the most frustrating to you lack of change over the past decade.

OSTER: We're still not doing enough research on outcomes that affect people's life but are difficult to measure. Like, how did your birth feel to you? Were you happy with it? What kind of satisfaction? How is your sex life feeling to you? Are you happy with it? We do almost none of that, or very little, and it means that we're not focusing research on improving the experience that people are having in pregnancy and birth and then in early parenthood.

DETROW: That's Emily Oster. Her new book with Dr. Nathan Fox is "The Unexpected: Navigating Pregnancy During and After Complications."

SCOTT DETROW AND EMILY OSTER: Thank you so much. Transcript provided by NPR, Copyright NPR.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

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