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An award-winning social scientist uses the tools of economics to debunk myths about pregnancy and to empower women to make better decisions while they're expecting.
Pregnancy is full of rules. Pregnant women are often treated as if they were children, given long lists of items to avoid -- alcohol, caffeine, sushi -- without any real explanation from their doctors about why. They hear frightening and contradictory myths from friends and pregnancy books about everything from weight gain to sleeping on your back to bed rest. Economist Emily Oster believes there is a better way. In Expecting Better, she shows that the information given to pregnant women is sometimes wrong and almost always oversimplified, and she debunks a host of standard recommendations on everything from drinking to fetal testing.
When Oster was expecting her first child, she felt powerless to make the right decisions. How doctors think and what patients need are two very different things. So Oster drew on her own experience and went in search of the real facts about pregnancy using an economist's tools. Economics is not just a study of finance. It's the science of determining value and making informed decisions. To make a good decision, you need to understand the information available to you and to know what it means to you as an individual.
Take alcohol. We all know that Americans are cautious about drinking during pregnancy. Official recommendations call for abstinence. But Oster argues that the medical research doesn't support this; the vast majority of studies show no impact from an occasional drink. The few studies that do condemn light drinking are deeply flawed, including one in which the light drinkers were also heavy cocaine users.
Expecting Better overturns standard recommendations for alcohol, caffeine, sushi, bed rest, and induction while putting in context the blanket guidelines for fetal testing, weight gain, risks of pregnancy over the age of thirty-five, nausea, and more. Oster offers the real-world advice one would never get at the doctor's office. The health of your baby is paramount, and with this practical guide readers can know more and worry less. Having the numbers is a tremendous relief -- and so is the occasional glass of wine.
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Emily Oster is an associate professor of economics at the University of Chicago. She was a speaker at the 2007 TED conference, and her work has been featured in the New York Times, Wall Street Journal, Forbes, and Esquire. She is married to economist Jesse Shapiro and is also the daughter of two economists. She has one child, Penelope.Excerpt. © Reprinted by permission. All rights reserved.:
Thank you, first, to my wonderful book team. My agent, Suzanne Gluck, without whom this project definitely would not have gotten past chapter 1 and who tells me straight up when it’s not quite there yet. Ginny Smith is some kind of secret genius editor who got this turned into a real book when I wasn’t even looking. Thanks to her, Ann Godoff, and the whole team at Penguin for enormous support, genius title creation, and all sorts of other things.
Huge thank you to Jenna Robins, who read everything first, rewrote most of it, made me sound like less of an economist, and without whose help I never would have gotten off the ground.
Emily L. Seet, MD, was an incredible medical editor (although any mistakes remain very much my own). Emily Carmichael created lovely graphs with little guidance. Jen Taylor provided invaluable contracting assistance.
I am grateful to all my ladies, most of whom helpfully got pregnant at the same time and shared their stories (sometimes without knowing they’d be book fodder): Yael Aufgang, Jenny Farver, Hilary Friedman, Aude Gabory, Dwyer Gunn, Katie Kinzler, Claire Marmion, Divya Mathur, and, most especially, Jane Risen, Heather Caruso, Elena Zinchenko, and Tricia Patrick.
Many colleagues and friends supported the idea and reality of this book at various stages. Including but by no means limited to: Judy Chevalier, John Friedman, Matt Gentzkow, Steve Levitt, Andras Ladanyi, Emir Kamenica, Matt Notowidigdo, Dave Nussbaum, Melina Stock, Andrei Shleifer, Nancy Zimmerman, and the More Dudes.
Actually putting the time into writing this would not have been possible without the help of many, many people in running my household. Most important of all, Mardele Castel, who has been Penelope’s Madu since day one, who makes Penelope happy and her parents relaxed, and who, very simply, makes it all work.
I’m lucky to have an incredibly supportive family. Thank you to the Shapiros: Joyce, Arvin, and Emily. To the Fairs and Osters: Steve, Rebecca, John, and Andrea. And to my parents: I couldn’t ask for better ones; Penelope is lucky to have you as her mormor and Grandpa Ray. Mom, I hope you feel the ninety-six hours of labor was worth it.
Finally, thank you to Jesse and Penelope, who, it goes without saying, were essential. You two make me happy every day. Penelope, you have the absolute best dad. I love you.
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 thirtieth birthday was around the corner.
We’d 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 eighteen months later our daughter, Penelope, arrived.
I’d always worried that being pregnant would affect my work—people tell all kinds of stories about “pregnancy brain,” and missing weeks (or months!) of work for morning sickness. As it happens, I was lucky and it didn’t seem to make much difference (actually having the baby was another story).
But 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 here is the thing: 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 I got pregnant, 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.
At the University of Chicago I teach introductory microeconomics to first-year MBA students. My students would probably tell you the point of the class is to torture them with calculus. In fact, I have a slightly more lofty goal. I want to teach them decision making. Ultimately, this is what microeconomics is: decision science—a way to structure your thinking so you make good choices.
I try to teach them that making good decisions—in business, and in life—requires two things. First, they need all the information about the decision—they need the right data. Second, they need to think about the right way to weigh the pluses and minuses of the decision (in class we call this costs and benefits) for them personally. The key is that even with the same data, this second part—this weighing of the pluses and minuses—may result in different decisions for different people. Individuals may value the same thing differently.
For my students, the applications they care about most are business-related. They want to answer questions like, should I buy this company or not? I tell them to start with the numbers: How much money does this company make? How much do you expect it to make in the future? This is the data, the information part of the decision.
Once they know that, they can weigh the pluses and minuses. Here is where they sometimes get tripped up. The plus of buying is, of course, the profits that they’ll make. The minus is that they have to give up the option to buy something else. Maybe a better company. In the end, the decision rests on evaluating these pluses and minuses for them personally. They have to figure out what else they could do with the money. Making this decision correctly requires thinking hard about the alternative, and that’s not going to be the same for everyone.
Of course, most of us don’t spend a lot of time purchasing companies. (To be fair, I’m not sure this is always what my students use my class for, either—I recently got an e-mail from a student saying that what he learned from my class was that he should stop drinking his beer if he wasn’t enjoying it. This actually is a good application of the principle of sunk costs, if not the primary focus of class.) But the concept of good decision making goes far beyond business.
In fact, once you internalize economic decision making, it comes up everywhere.
When Jesse and I decided we should have a baby, I convinced him that we had to move out of our third-floor walk-up. Too many steps with a stroller, I declared. He agreed, as long as I was willing to do the house shopping.
I got around to it sometime in February, in Chicago, and I trekked in the snow to fifteen or sixteen seemingly identical houses. When I finally found one that I liked (slightly) more than the others, the fun started. We had to make a decision about how much to offer for it.
As I teach my students, we started with the data: we tried to figure out how much this particular house was worth in the market. This wasn’t too difficult. The house had last sold in 2007, and we found the price listed online. All we had to do was figure out how much prices had changed in the last two years. We were right in the middle of a housing crisis—hard to miss, especially for an economist—so we knew prices had gone down. But by how much?
If we wanted to know about price changes in Chicago overall we could have used something called the Case-Shiller index, a common measure of housing prices. But this was for the whole city—not just for our neighborhood. Could we do better? I found an online housing resource (Zillow.com) that provided simple graphs showing the changes in housing prices by neighborhood in Chicago. All we had to do was take the old price, figure out the expected change, and come up with our new price.
This was the data side of the decision. But we weren’t done. To make the right decision we still needed the pluses and minuses part. We needed to think about how much we liked this house relative to other houses. What we had figured out was the market price for the house—what we thought other people would want to pay, on average. But if we thought this house was really special, really perfect, and ideal for us in particular, we would probably want to bid more than we thought it was worth in the market—we’d be willing to pay something extra because our feelings about this house were so strong.
There wasn’t any data to tell us about this second part of the decision; we just had to think about it. In the end, we thought that, for us, this house seemed pretty similar to all the other ones. We bid the price we thought was correct for the house, and we didn’t get it. (Maybe it was the pricing memo we sent with our bid? Hard to say.) In the end, we bought another house we liked just as much.
But this was just our personal situation. A few months later one of our friends fell in love with one particular house. He thought this house was a one-of-a-kind option, perfect for him and his family. When it came down to it, he paid a bit more than the data might have suggested. It’s easy to see why that’s also the right decision, once you use the right decision process—the economist’s decision process.
Ultimately, as I tell my students, this isn’t just one way to make decisions. It is the correct way.
So, naturally, when I did get pregnant I thought this was how pregnancy decision making would work, too. Take something like amniocentesis. I thought my doctor would start by outlining a framework for making this decision—pluses and minuses. She’d tell me the plus of this test is you can get a lot of information about the baby; the minus is that there is a risk of miscarriage. She’d give me the data I needed. She’d tell me how much extra information I’d get, and she’d tell me the exact risk of miscarriage. She’d then sit back, Jesse and I would discuss it, and we’d come to a decision that worked for us.
This is not what it was like at all.
In reality, 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.
And then we got to prenatal testing. “The guidelines say you should have an amniocentesis only if you are over thirty-five.” Why is that? Well, those are the rules. Surely that differs for different people? Nope, apparently not (at least according to my doctor).
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. This was frustrating enough. Making it worse, the recommendations I read in books or heard from friends often contradicted what I heard from my doctor.
Pregnancy seemed to be a world of arbitrary rules. It was as if when we were shopping for houses, our realtor announced that people without kids do not like backyards, and therefore she would not be showing us any houses with backyards. Worse, it was as if when we told her that we actually do like backyards she said, “No, you don’t, this is the rule.” You’d fire your real estate agent on the spot if she did this. Yet this is how pregnancy often seemed to work.
This wasn’t universal, of course; there were occasional decisions to which I was supposed to contribute. But even these seemed cursory. When it came time to think about the epidural, I decided not to have one. This wasn’t an especially common choice, and the doctor told me something like, “Okay, well, you’ll probably get one anyway.” I had the appearance of decision-making authority, but apparently not the reality.
I don’t think this is limited to pregnancy—other interactions with the medical system often seem to be the same way. The recognition that patient preferences might differ, which might play an important role in deciding on treatment, is at least sometimes ignored. At some point I found myself reading Jerome Groopman and Pamela Hartzband’s book, Your Medical Mind: How to Decide What Is Right for You, and nodding along with many of their stories about people in other settings—prostate cancer, for example—who should have had a more active role in deciding which particular treatment was right for them.
But, like most healthy young women, pregnancy was my first sustained interaction with the medical system. It was getting pretty frustrating. Adding to the stress of the rules was the fear of what might go wrong if I did not follow them. Of course, I had no way of knowing how nervous I should be.
I wanted a doctor who was trained in decision making. In fact, this isn’t really done much in medical schools. Appropriately, medical school tends to focus much more on the mechanics of being a doctor. You’ll be glad for that, as I was, when someone actually has to get the baby out of you. But it doesn’t leave much time for decision theory.
It became clear quickly that I’d have to come up with my own framework—to structure the decisions on my own. That didn’t seem so hard, at least in principle. But when it came to actually doing it, I simply couldn’t find an easy way to get the numbers—the data—to make these decisions.
I thought my questions were fairly simple. Consider alcohol. I figured out the way to think about the decision—there might be some decrease in child IQ from drinking in pregnancy (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?
The numbers were not forthcoming. I asked my doctor about drinking. She said that one or two drinks a week was “probably fine.” “Probably fine” is not a number. The books were the same way. They didn’t always say the same thing, or agree with my doctor, but they tended to provide vague reassurances (“prenatal testing is very safe”) or blanket bans (“no amount of alcohol has been proven safe”). Again, not numbers....
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