“Covid Updates, Expecting Better 2021, and The Family Firm” – with Emily Oster

Links to Purchase Books:

• The Family Firm: A Data-Driven Guide to Better Decision Making in the Early School Years

• Expecting Better: Why the Conventional Pregnancy Wisdom Is Wrong–and What You Really Need to Know

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Emily Oster, welcome back to the podcast. It’s great to catch up with you. How you doing?

Emily: I am all right. How are you doing?

Dr. Fox: I’m doing well. COVID is still prevalent. It’s apparently still around. Who knew?

Emily: Yeah, it’s not over it would seem.

Dr. Fox: How’s your summer been? Everything okay? You get to spend any time with your family?

Emily: Yeah, we’ve gotten to have some family time, the kids have gotten to go to camp. So it felt somewhat normal, although I think it’s hard to really say normal these days.

Dr. Fox: Right. Right. The new normal. So I think pretty much all my listeners know who you are. But for maybe the one or two out there who don’t, you’ve been on the podcast before, which is not your claim to fame but it is in my worlds. But obviously you’re an economist, you’re a professor, you’re a writer, you are a blogger, you’re a parent, and you have great books out there. We’re going to be talking about them today as well. And generally, you’re just one of my favorite people out there. So I’m really happy to get to talk to you from time to time when our schedules allow it.

Emily: I’m very excited to get to talk to you as well. Yes, I think you did a good summary of all the weird jobs that I have these days.

Dr. Fox: Yeah, you definitely have an eclectic CV, I would say.

Emily: It’s true.

Dr. Fox: Which is good. It’s good to be out there. So let’s just start with some COVID because, you know, you sort of got really active in the COVID world when it started in terms of looking at the data, obviously, which is what you do, and explaining it to people, which is also what you do really well and trying to sort of, you know, funnel all of that crazy data and, you know, disparate information to people in a way that’s understandable. So where are you now with all your COVID activities? Are you doing anything formal or is it really just sort of ad hoc with your blogs?

Emily: Yeah, so I’ve still been writing a lot in the I think we’re calling it a newsletter these days. Yeah.

Dr. Fox: Is that right?

Emily: Yes. Totally a newsletter. That’s a blog that gets emailed to people. FYI, that’s the 2021.

Dr. Fox: It’s a periodical now. Okay.

Emily: Exactly. So I’ve still been doing, you know, a lot of writing there mostly around kind of trying to help people navigate this period, which I think remains pretty uncertain and people are kind of still trying to just figure out, particularly pregnant people and people with small kids kind of trying to figure out what the next steps are. So been doing a lot of that. And then actually, more formally, I’ve been doing some work on data around schools and trying to put together some information about schooling rules over the last year, and kind of with a bunch of partners just trying to understand better sort of what was happening with kids over the last year. So there’s still some COVID stuff in my world these days.

Dr. Fox: Got it. And how happy have you been with the vaccines? Because when we spoke last time, it was right when the vaccine was getting released and we were both pretty positive about it saying it looks like a great thing, data looks good, it looks safe, it looks like it’s gonna work. And six months later, what are your thoughts on it thus far?

Emily: I continue to think that vaccines are a wonder of modern medicine. You know, I think that the messaging around vaccines has obviously gotten way more fraught and more complicated. I think the high level takeaway for me still is just that these vaccines are incredibly effective, and how lucky we are at how accessible they are and how effective they’ve maintained against the variations on the virus. I think that that message is sometimes getting a little bit lost, but really, these are pretty extraordinary vaccine options that we have.

Dr. Fox: Yeah, I mean, I think that right now people look at it, and everyone’s sort of fine tuning like, for the people who got it, “Do I need a booster? Do I not need a booster? When do I need a booster? What does the booster look like?” You know, all these things. And the people who have yet to get it, you know, they’re sort of, you know, “Should I get it? Should I not get it?” But if we, again, on a high level, if we could go back a year and a half and bring this vaccine with us and give it to everybody in the world, we would have prevented millions of deaths, millions. It’s crazy. Like I think people forget that. Like that’s how effective it is. Those people who all died in COVID would be alive. Yeah, maybe not 100% of them, but 99%, 95% of them, whatever study you look at, it just would have been a totally different world had that vaccine been available beforehand.

Emily: Yeah. Yeah, I think that’s right. And I mean, I think that’s kind of a good frame to put around it, I think, because part of what has happened even the last few weeks, we’re seeing some breakthrough infections that I would distinguish that, you know, from breakthrough disease, we’re seeing breakthrough in fractions and we’d expect that. I mean, basically, there’s almost no vaccine on the planet that’s going to prevent you from…prevent people from getting any infection. The goal of the vaccine is largely to prevent you from getting seriously ill. And these vaccines are incredibly good at doing that, like so, so, so doing that. And I think that we’re going to sort of need to remember that that’s the goal of the vaccines that there’s something in the messaging that’s getting…they’re always like so good that people thought that just nobody would ever get COVID anymore and that’s not a realistic expectation of the vaccines. That’s making it a little bit challenging to talk about them sometimes.

Dr. Fox: Yeah. And also I think that part of it is the messaging that’s out there in the mainstream media, but certainly, like, just out there online when people look at percentages, they say, “Oh, you know, there’s this many people who got the vaccine, but still tested positive,” or, “This many people who got the vaccine and still actually ends up in the hospital.” And obviously, there’s going to be somebody who gets the vaccine and unfortunately still passes away. And that’s all true because nothing’s 100% effective. But, I mean, the difference is just astronomical. I mean, you know, a year and change ago in the hospital, they didn’t have enough beds. I mean, it was just all COVID patients, and now, yeah, there’s some COVID patients there, but it’s nothing like it was before. With all the variants and whatever it is that’s out there, it’s not like it was before. And that’s because of the vaccine. It’s not because of, you know, all the social distancing that we’re doing, it’s because of the vaccine.

Emily: Yeah, absolutely. It’s because of the vaccine. That’s just the way it is.

Dr. Fox: How do you talk to people about the Delta variants? It seems like that’s like, you know, the new big bad thing on the block that everyone wants to be afraid of? And, you know, okay, COVID is out but now the Delta variant, you know, it’s like “Terminator II.”

Emily: That’s totally right. I mean, I think the first thing is some of this rhetoric seems like people think the Delta variant is like, in some way, like, totally different on all dimensions. And so the main thing I’ve been trying to convey to people is actually there is a way in which it’s different, which is it is more contagious. That’s like, full stop seems to be true, seems to be quite a lot more contagious for various reasons. But it doesn’t seem to be generating more severe disease. It doesn’t seem to be generating relatively more severe disease in kids, or pregnant people, or whatever. It basically looks like the same disease, just way more contagious.

That’s helpful for people because they kind of already thought about what to do in the face of COVID. And so if you frame it like that, and you say, “Look, this is a more contagious version of something you have already thought some about.” And so when you look out at the world, you want to think about, you know, what are the case rate is looking like, what is the risk of infection? It’s all the same kind of calculations, just sort of dialed a little bit for the contagious. I mean, I hope that’s been helpful for people in part because it normalizes it a little bit, and you know, it helps them turn this from something that’s totally new into something that’s only sort of partially new.

Dr. Fox: You know, if you think about other viruses like the flu, it mutates every year. There’s a different flu vaccine that comes out every year. I don’t think people realize that the flu vaccine is different every single year. And that’s interesting for a lot of reasons. One, it just shows that some viruses continue to mutate and we continue to develop vaccines. Number two, this idea of a new vaccine never being introduced before. Every single year, there’s a new vaccine for the flu, and people don’t think of it as a new vaccine. We just don’t know how COVID is going to land. Is it going to end up being like the flu where we have to sort of, you know, rejigger it every year and get a different COVID vaccine based on the variants out there? Or is it going to be something like measles, let’s say, where you get your series of vaccines at whatever age and then you do potentially need a booster later, but you might not? Or is it something like tetanus where you for sure need a booster every X amount of years? We just don’t know because it hasn’t been around long enough to figure that out. But whatever those options are, they’re all fine. Whether you need it every year, every 5 years, every 20 years, or just once, I mean, who cares? Like whatever it is, it is.

Emily: There’s this idea of, oh, is it fear of the boosters? And I think people are sort of having a hard time even understanding in some cases, you know, what do we mean by a booster? Because, of course, you could need two different things. And you sort of said, “Well, is it like tetanus? Is it like the flu?” But the reason that you have the booster in tetanus is different from the reason you have flu vaccine every year. Right? I mean, the flu vaccine every year because it’s a different strain, effectively, a different variant. You’re having the tetanus booster because immunity waned, not because it’s status is changing all the time. And so, you know, we could need a COVID booster of the same thing again, we could need a COVID booster that’s different, sort of different version, different strain later. And so I think we’re just, you know, we’re not going to know those things. And sometimes I feel like there’s a little bit of a like, “Well, why don’t we know that? You know, why don’t we know what’s going to happen in five years?” Well, it hasn’t been around for five years. So like it’s kind of an unrealistic expectation.

Dr. Fox: Right. “Why don’t we know the future?” We don’t.

Emily: Exactly. It’s like, “Can’t we go to the future? If we go to the future we could have brought the vaccine back and that would have been best.”

Dr. Fox: My daughter asked me last night what are the chances I thought that her school will end up being remote again this year and I said, “Oh, my God, I hope not.” Well, what are your thoughts about that? Are there going to be schools that are still remote because of fear from this, you know, Delta variant or whatever it is? Or do you think pretty much everyone is done with that?

Emily: I think it will be almost all in-person. I think the piece that I’m unsure about is how much disruption there will be. So, you know, if we have a more contagious variant and a lot of unvaccinated kids, I can see, you know, some quarantine stuff going on. And I think that’s something will need to be navigated pretty quickly. But in terms of, you know, will schools try to open in-person? I think that they will. I think the cards are lining up, the important groups are lining up very strongly behind the idea of in-person learning. And I think that, you know, we kind of realized the last year was not good for kids.

Dr. Fox: There’s a couple of kids out there who are like, “No, this is great. I’m more than happy to be home. I kind of don’t like the social situation at school. This is better for me.” But I think pretty much everyone else agrees it’s better for everyone to be in school. What have your thoughts been about the vaccine for, I guess, first, I’ll say the teenagers because it is approved for them, and then for, let’s say, the 2 to 12-year-olds who are coming up next?

Emily: This has proven to be actually a somewhat more difficult thing to talk about and it is unlike the sort of vaccines for older adults, policymakers have disagreed on this. And I don’t mean like, you know, Marjorie Taylor Green, I mean, like, you know, across countries. So the UK is not the sort of consistently recommending vaccines for 12 to 15, I think. I think they’ve said that, you know, some kids are at like an age that can get it, but they’re not going to do that in a sort of uniform way. And I think the reason for that is that the calculus is the sort of risk benefit for that group is different, that, you know, their risk of serious illness is extremely low. And, you know, the vaccines are very safe, but every vaccine, everything we do carries some risk. And so, you know, we’re now trading off a, you know, tiny, tiny risk against a benefit, which at a minimum is smaller than the benefit for, you know, an 85-year-old.

Having said that, I think, you know, for the 12 to 15-year-olds, in particular, that’s actually a pretty high risk group on terms of cases. So not for serious disease but this is a group that’s mixing a lot, you know, they see other people in the older edge of that age range they’re kind of having maybe some interactions with other people. And we are seeing a fair amount of sort of case rates in that group. So I think pushing vaccines in that age category seems like a reasonable approach. I mean, it’s for no other reason that it will help us keep the schools open. For younger kids, you know, again, I’m kind of in the space of like let’s not have hypothetical arguments. So I think sometimes people, you know, they want to say, “Well, let’s decide now what we’re going to do. Are you going to agree with me? Are we all going to do the same thing?” Well, you know, we haven’t seen any of the data on that. So like I anticipated vaccinating my kids and I plan to do it as soon as I can. But I also think before we have that argument, let’s wait to see, you know, what Pfizer or Mordena come up with on safety data, what we’re seeing in the trials, and then we can, you know, have a non-hypothetical argument whether it’s actually an option.

Dr. Fox: You know, it’s really interesting because for, you know, all of these age groups, let’s say under 18, for all the kids, as you said, the data has pointed from day 1 that COVID is not particularly dangerous to them as compared to the flu or sort of anything else they might catch. And so it really it shouldn’t have been such a high stakes decision about vaccinating or not vaccinating. And I can tell you like with my own kids, the reason we were so on the side of vaccinating, in addition to just in general, I tend to be pro-vaccine, but it was logistical. It’s like these kids, you know, in terms of like going to school, going to camp, going to mall, like just doing things that they want to do, it’s so much easier if you’re vaccinated because if you say, “I’m vaccinated,” it’s like, “Okay, you know, it’s like you got a pass.”

Emily: Your get out of jail free card, right. Yeah.

Dr. Fox: And so, you know, there’s all this stuff about having to wear a mask, not having to wear a mask. Everything is going to be more permissive for people who are vaccinated. And so even if I don’t think medically it makes a huge difference whether my 14-year-old does or doesn’t get a vaccine, which I believe is the case, I don’t think medically it does make a huge difference because both options are low risk. I think that just for logistics because the way people are treating COVID and restrictions and distancing, you may as well get the vaccines. You’re gonna live normally or close to normally. And that’s sort of how we decided for our kids. And then, you know, they were part of that decision and they all agreed.

Emily: Yeah. I mean, I think there are a lot of people in that space. And I think I will say kind of talking to another parent the other day who said, “You know, I wouldn’t vaccinate my five-year-old.” And he said, “Would you do your kids?” And I said, “Absolutely.” And he said, “You said that so fast.” And I was like, “Look, if for no other reason than the logistics,” you know, I’m like, “I’m tired of this. Like I did quarantine and all this other military stuff.” So I think there’s a logistical piece is absolutely there. I think that there is a kind of pushback on that from some people which says, you know, “Look, if kids are this very low risk group and, you know, particularly with the younger kids, they’re not only low risk themselves, but they’re actually fairly low risk in terms of transmission, you know, not no risk, but fairly low risk, you know, why should we be putting all these restrictions on them in the first place?”

Dr. Fox: Yes, I agree.

Emily: And, like, you know, it’s like, they shouldn’t have to get vaccinated because we should just be letting them do whatever, anyway, because they’re at low risk. And I think there is certainly a set of people who would express that too.

Dr. Fox: I think that the data would point to that, that it’s not risky for them. And, you know, looking at it, you know, #science, there really is no reason for kids to be, you know, quarantining and distancing and masking and all these things. I just think the problem is that that train has left the station, I just don’t…

Emily: That train is off.

Dr. Fox: Yeah. I mean, we had this conversation a year ago saying, like, “Why are we doing this for our kids? Like we should let them out and get antibodies and roam the earth?” But again, that’s just not how people have done it. And it’s just not realistic to expect everyone to say, “Okay, you know, kids, everyone, you’re done.” So I think that that’s probably it. You know, the interesting thing when I talk to people who are really hesitant about the vaccine, it’s understandable, it’s a vaccine, it’s new, people don’t want to put things in the body they know. The way I look at and I say to them, I say, “Listen, if you don’t get the vaccine, you know, you can mask, you can distance. It’s not a matter of, if you’re going to get COVID, it’s when? This is a virus that’s there. It’s never going away. Viruses don’t like easily eradicate, especially when they mutate.”

So I said, “You’re just pushing off the inevitable. You’re gonna get COVID at some point from somebody. You can’t be, you know, in N95 masks, indoors alone the rest of your life. So it’s, again, you’re going to get it.” That’s number one. And if you’re not so afraid of getting it, okay. But whatever fear people have that the vaccine might hypothetically do to them 10, 20, 30 years down the road, whether it’s infertility or something or this or that, why wouldn’t you be afraid of the virus doing that 10, 20, 30 years down the road? That’s much more biologically likely to harm you in the long-term than a vaccine would. And so I just think it doesn’t make any sense sort of like logically to put off the vaccine for fear of some hypothetical long-term problem.

Dr. Fox: Yeah. I mean, I think that’s exactly right. But I think where people sometimes sort of make this argument about waiting is, you know, it still feels new. Like I want to see more data. And I think they’re, you know, sometimes what, when people talk to me about this, they sort of say, you know, “I hear that.” But if you’re going to say that, you probably want to say what you’re waiting for. Like are you waiting for another three months? Are you waiting for full FDA approval? Or are you waiting for…like what exactly are you going to think is sort of sufficient information? Because if the answer is, as you say, like, “Well, I really need to see, you know, in 20 years, whether something happens,” then you know, you can get COVID before that for sure. Right?

If what you’re saying is, “I just feel like I want to wait for FDA approval,” well I don’t know what the FDA is waiting for, but like, at some point, I assume that they will be doing that. And then, you know, that’s not so many months off. So maybe it’s more reasonable to say, “Okay, well, you could wear an N95 and not leave your house for another, you know, two months,” or whatever that timeframe is, but I think it is important to be clear on that at least even with yourself.

Dr. Fox: Yeah, yeah. And I want to state for the record for everyone listening, the business about COVID vaccine and infertility is complete garbage.

Emily: Complete garbage.

Dr. Fox: Totally made up. It’s like literally…

Emily: Made up garbage.

Dr. Fox: …it’s fake Facebook-ism. It’s crazy. It’s just totally fake, totally fake. So since we’re talking about what’s fake and what’s real, let’s transition to your great book, “Expecting Better,” which is the first book you and I spoke about on this podcast. It’s I guess originally 2013, right? Eight years ago?

Emily: Yeah.

Dr. Fox: Yeah. And then you revised it in 2016. And now there’s a new revision that is either about to drop or just did. Again, the book is called “Expecting Better: Why the Conventional Pregnancy Wisdom is Wrong – and What You Really Need to Know.” We spoke about this book before on the podcast, but just as a brief review for those who may be new to the podcast, what’s this book about?

Emily: It’s about decision making in pregnancy. And it’s really a sort of almost like I did say an alternative to “What to Expect When You’re Expecting,” but you’re really diving into the data behind a lot of these common sort of pregnancy restrictions or behind the kinds of decisions that you have to make in pregnancy. So it talks about prenatal testing, talks about things like, “Can you have sushi and, you know, what is the evidence really say on that?” Talk something about labor and delivery. It’s a book about pregnancy for people who want to know the answer to the question like, “Why did you say that?”

Dr. Fox: Yeah. And the interesting thing again is your background is as an economist, like as someone who just looks at data, you’re not a physician. You don’t walk into this a pregnancy expert other than being pregnant, obviously. But what’s the story that you actually wrote this book?

Emily: As I was experiencing my own pregnancy, I realized I had a lot of questions. I didn’t feel like they were always well answered by existing books or even, you know, to some extent by my doctor. But I also realized that a lot of the tools that I use in my job as an economist where I think about data all the time, a lot of those tools were really useful in thinking about a lot of the evidence behind these pregnancy, these sort of common pregnancy restrictions, that kind of led me into the book and I started doing a lot of research in service of my own pregnancy and ultimately kind of writing it up. So you’re right, I sort of come from a very different direction, much more on the data side than the kind of medically side.

Dr. Fox: It’s interesting because my relationship with the book as an OB, as an MFM, I don’t read a lot of books on pregnancy unless it’s maybe a textbook. I’m going to the sources, the articles, the research and this and, you know, to learn about it and talk about it with people. But I was with a patient, a couple, and they said, “You know, there’s this book, and you really need to read it.” And I’m like, “Oh, God.” I was like, “Why do I need to read a pregnancy book?” They’re like, “Because it sounds like everything you would say. It sounds like you wrote it.” So I said, “All right. Fine. Like whatever.” I went to Amazon and bought the book, and it’s a relatively quick read, you know, when I read and I was like, “Oh, my God, this is awesome.” I was like, “Who is this woman?” I was like, “She nailed it.” And it was just awesome. So, you know, I cold-called you, we went out to lunch. And it’s just been this is the book that I recommend to my pregnant patients. I say, “This is the book you should read. Start here,” I say, “Then go listen to my podcast, and you’re good to go.” Now that you’ve done so many other things over the past eight years, is this still like the thing you’re most known for in the, let’s say, non-PhD world?

Emily: Yeah, I think so. I mean, you know, I now have a couple of other books. For most people who kind of read the stuff I do, this is sort of still the entry point, the first thing that that they see. In weird sense it’s become what I’m known for the PhD world also. So, you know, I’m an economist, I’m a professor, I write academic papers, and so on. But when I go and give talks at places, most of what people want to talk about now is the books because everybody…like this is an experience that is so widely shared by people. And so, you know, they were pregnant or their spouse is pregnant, like I feel like I’m sort of touching people’s lives in ways that are maybe different than my papers. Nobody ever wants to talk about my papers.

Dr. Fox: I think it’s also in a sense, the books are, I mean, they’re groundbreaking in a sense that there really weren’t books out there written for regular folk that made an attempt to go through the data and explain the data and talk about the data. You know, it was really just someone’s opinion, someone’s, you know, “Oh this is what I think you should do.” Just like a list of recommendations or explaining what things are happening. But to actually go into, “This is what’s behind this recommendation and this is why I’m saying A versus B,” I don’t know of anyone that did that, again, for pregnant women as opposed to for doctors, let’s say. And I think it opens up this, like, access for people into this world, which is great. That’s how it should be, obviously, to whatever degree people can understand this, and you make it very understandable.

I just think it’s a terrific resource for people to really understand what’s going on. And you did really debunk a lot of the crap that was out there in terms of recommendations and, you know, by whatever it was, magazines, by friends, family, even doctors, and you backed it up with data. So it’s very hard for people to argue that you’re wrong. “Like show me the data if you think I’m wrong.”

Emily: Yeah. I mean, I think the kind of thing I realized when I look back at what did I think was missing in this space and why did I ultimately write the book, I think part of it was this feeling of like, “Okay…” Not that there were no books that said the things I agree with, like there actually, were some books which kind of you cobble them together, and basically, they’re like, “Okay, I kind of agree with the recommendations.” But nobody tried to explain why. And there was kind of no resource that would say, like, “Here’s the recommendation, and like, kind of don’t take my word for it.” Or, “Here’s why I think that.”

The thing that I realized was that there was a way to explain why I thought these things in a way that was accessible to people. And I think that’s the thing I’ve spent most of the last kind of decade trying to do better at is how do I take like an academic literature and help people understand what are the issues with the data, what’s good about the data, what’s not good about the data, what are the things that we can glean out of this? And I think that kind of translational writing has become sort of my whole life in the last 8 or 10 years.

Dr. Fox: Yeah. Well, listen, there’s a reason you’re successful. You’re good at it. I mean, it’s hard to do that and you do it really well, better than most. And so you do have this talent and this skill to take that complicated information and data and analysis and present it in a way that people can get it. It’s understandable and I think that’s terrific. So the book now is, I’m reading off the cover, fully revised and updated.

Emily: Fully revised and it’s special foreword by amazing doctor Fox.

Dr. Fox: Yeah, I was gonna say, in addition to redoing the whole book just to put a new foreword in there by me, which was a great honor, by the way, and I thank you for that. And I actually believe what I wrote, I’m like, “Get this book. It’s a good book.” Other than that, which is enough to redo a book, what are some of the highlights that people should look for in the new version or the updated version compared to the original or the 2016 version?

Emily: A few things. So one is I did a fair amount of revision of kind of like talking to people about how they think about birth, in part because of the arrive trial, which sort of hadn’t made it into the last revision. So sort of thinking about choices around induction and timing of induction, thinking about some choices around C-section. So I sort of like rejiggered that whole section a bit. But then, you know, another piece that people kept asking me about was pot. I mean, okay, like, you know, people are interested in in marijuana and pregnancy and finally by the time I kind of got around to doing this, there’s a little bit more better data than there was the first time to kind of come down on the view that you probably shouldn’t be doing that until we know more. And then there are a few other things a little bit of stuff on skincare, which, I guess I don’t do a lot of skincare. And so it did not occur to me that other people do care about their skin. But I put some of that in. Well, and then there’s just some general updating. So, you know, always with something like this, you want to make sure that the data is as reflective of the sort of current state of the literature as it can be.

Dr. Fox: Right. So let’s talk about pot and pregnancy. Because just like how your readers are very interested in it, I know my listeners are just eagerly awaiting the data on marijuana use in pregnancy. So what did you find? I know, there’s new data out there, and what exactly were you looking at when you looked at this data?

Emily: Yeah, so I think like, in some ways, the best data that we have at this point comes from Canada. So just to sort of step back, like yes, why is it so hard to figure this out? Don’t a lot of people use pot? Yes. But because it’s until recently been pretty widely illegal, it’s a hard thing to collect data on. And people who are, you know, smoking marijuana are different in other ways and so on. And so that was sort of very hard. Now, with the advent of sort of more legalization and those changes, we’ve been able to get better data. And probably the best data sort of links marijuana use in pregnancy in this sample to some sort of short term birth outcomes and does find, you know, some evidence of some kind of slightly worse birth outcomes for infants whose mothers use more marijuana during pregnancy. And the changes are relatively small and it’s still a little hard to sort of fully learn from the data and a lot of the questions that people want to ask about long term, you know, psychological impacts on kids, I think we just don’t really have good data on that.

But I sort of where I come into curious what you tell people, I think where I come down on this is that, you know, as a sort of recreational activity, I think the data is not supportive of that or at least, I would urge caution. I think where it gets a little more complicated is some people use this for very severe nausea were actually like some of the worries about marijuana use, like an increased risk of preterm birth are also the same kinds of worries you’d have about hyperemesis. And so there’s more of a kind of doctor conversation there.

Dr. Fox: Like what you said, there was a very large study that associated marijuana use with some adverse outcomes. And it was a big study and the association was what we call statistically significant and they did a pretty good job of trying to compare apples to apples, you know, they did a matching technique. So, you know, one of the big issues with these is, like you said, if you take your, you know, marijuana users, and you compare them to non-users, well, if they’re only different in one group is using marijuana and one group isn’t, then fine, then you’ll learn something. But obviously, you know, there’s gonna be a lot of differences. There may be differences in ages, they may be difference in weights, they may be different whether they drink or whether they smoke cigarettes. And so you have to sort of like tease through all of those variables to try to, you know, compare the same and they and they did that. They tried to do that.

And when they did that, the people who use marijuana still did worse. The problem with that is you can’t look at every variable possible. They just looked at the ones they had. And so we don’t really know for sure what to do with this but I think it is biologically plausible that marijuana could affect the baby. And I think that, like you said, we don’t really know that it’s safe. So I generally recommend against using it in pregnancy. My gut is that it’s not going to be as dangerous as alcohol and it’s not going to be as dangerous as smoking, you know, tobacco cigarettes, you know, classic cigarettes. Like if I had to rank them, you know, it would be probably in the bottom. But there could be a negative effect.

Now maybe with more time, we’ll learn that there is no negative effect. Or maybe we’ll learn, like you said, it’s small enough that maybe it’s outweighed in certain instances, like someone who has certain pain syndromes, or a lot of nausea, or maybe severe anxiety, but there’s a lot of reasons why someone might use it therapeutically and maybe it’ll outweigh the risks there. But it’s very hard to know and we don’t know exactly what the risks are. And then the whole entirely unknown box are edibles, right? And the different components of the different doses and different ways, and we just have no idea if that’s going to have any effect whatsoever, negative some people are using edibles for nausea and it seems to work for some people. But again, we just don’t know if there is risk, and if so what the magnitude is. So it’s hard to be precise but my gut is that it’s not a great idea now and maybe we’ll learn more so we can sort of quantify that for people.

Emily: Yeah. I mean, I think that, you know, part of what’s going to make this hard is my guess is to the extent that there are negative effects, they’re probably small. As you kind of try to dial into these more narrow questions, you’re asking like, “What about edibles? What about this kind of edible? What about…” Like we’re never going to be able to have the power in any study to figure out the answer to those questions. And so they’re sort of going to have to accept that they’re kind of some of the things we’re just not going to have answers, we’re not gonna have answers that we that we really sort of trust.

Dr. Fox: Yeah. And also you have to sort of sometimes look at the alternatives. I mean, again, as someone’s like, I’m either going to smoke marijuana or I’m not, okay, fine. But sometimes people don’t make choices like that. For example, like, if you look at cigarettes, there’s data on the harms of E-cigarettes or vaping. And yeah, there are harms with it. But it’s worse if you’re smoking instead. And so if using E-cigarettes or vaping to get off of cigarettes, it’s probably a good idea. Whereas if you’re doing it as compared to nothing, it’s probably a bad idea. So a lot of this has to be taken into context, obviously. But it is interesting, and everyone’s asking this question. So there are a lot of people collecting data but the only way to know for certain is to like randomize people to use these or not. And maybe they’ll do that in small studies for certain conditions, but then you really won’t learn the risks as much. It’s hard, it’s hard to get good data on this.

Emily: It’s hard. I totally agree. We don’t like to experiment on pregnant ladies.

Dr. Fox: So my well-skinned friend, what did you find about skincare for all those who do suffer from ailments that requires skincare?

Emily: So I think, you know, the biggest question people have is around, you know, retinols. Accutane is like one of the worst things you can have during pregnancy. This is an acne drug. But then there’s a question of like, “What about a topical retinol?” And the kind of evidence is a little more difficult to parse, although I basically think it comes down on the idea that there was probably some birth defect risk, or at least some, you know, potential birth defect risk associated with retinols in pregnancy. And so, you know, it’s not that if you accidentally use them before you know you’re pregnant, like, should you panic? No. Is this something that one should continue using during pregnancy? I would have said, I think the data suggest not. But then there’s other things, you know, like benzoyl peroxide wash, which people said, “Well, I would never let that near my face.” Where I think in fact, there’s, of course, no reason not to use that. So you can still wash your face.

Dr. Fox: Yeah, I think pretty much anything. It’s very hard for something topical, to be absorbed enough to affect a baby, I suppose there’s certain like hormones like testosterone cream that could do it. But that’s very unusual. And, you know, in terms of like the topical retinols, my guess is it doesn’t do anything. People stop it because, I mean, they’re like, “Why would I take the risk?” And they sort of just feel like, it’s not worth it in that sense. But I bet it’s not absorbed enough, you know, systemically that if it gets to the baby and cause anything dangerous, but the general recommendation is not to use them in pregnancy. That’s more I think abundance of caution as we’ve learned to say over the past couple years. And one of the interesting updates that’s come since your last edition, and this is something you and I wrote about together, was there was a really great study that helped I would say lend support to our existing belief that sleeping on your back was fine in pregnancy.

Emily: I’d really like to give an example because I think it illustrates some of the issues with evidence. So there was this sort of idea that sleeping on your back during pregnancy was a risk for stillbirth. So not, you know, like not a minor risk, like a risk for a very, very bad outcome. But all of the data on that was based on these case control studies where they had, you know, cases in which people have had a stillbirth and then they collected some information about them, including asking them their sleeping position. And then they had a bunch of, you know, comparison people who hadn’t had a stillbirth and they asked them the same kinds of questions.

And those studies are just like they’re really problematic. I mean, sort of that research design is really problematic. It’s problematic because it’s hard to…you know, the groups may be different other ways. But it’s problematic also because the way you’ve selected the people is totally different. And the way that they’re going to think about answering those questions, particularly around something where actually it may be hard to remember what happened, just not a very good kind of study. So what was so great in the last few years was that this study came out which collected data prospectively. So ask people, you know, about their sleep position, and then follow them over time. And they were able to observe complications and stillbirth rates and miscarriage rates and they and they found basically no differences across the groups.

And, you know, that is very compelling and also suggested it’s fine to sleep in whatever way you find comfortable. And that’s actually kind of consistent with other things we see from science where you can look at questions like, you know, is there a lot of restricted blood flow when people are lying on their backs? And, you know, would you move off your back if you were uncomfortable? Yes. And so there’s kind of a lot of reasons to think that this would be true, but it was great to actually see it in data. I think it’s reassuring for a lot of pregnant women who like to sleep which is all pregnant women.

Dr. Fox: Hopefully, listen, in any way someone can sleep when they’re pregnant. I mean, it’s hard enough to sleep when you’re pregnant to have people telling you, “Oh, now you have to be on your left side and this.” And it’s just it’s really it’s unkind to pregnant women because then they think that, you know, if they don’t sleep a certain way, they’re harming their baby. I mean, that’s just a lot of guilt to throw on somebody that’s totally unnecessary and unwarranted. Do you feel compelled now that you’ve updated the book to, like, keep a running list of things and, you know, update it every X amount of years? Is that like daunting to you or is it exciting? How do you feel about that?

Emily: This last update was a lot of fun because I got a little bit more…like they gave me a little bit more freedom to kind of rethink things. You know, it was fun to revisit, to revisit the book and also to revisit like my own, you know, experience of having written a book actually on this now, and I recorded the audiobook myself, which I hadn’t done the first time. So I got to kind of read it out loud and it was, I don’t know, it was fun to think about, oh, like I remember, you know, my kids are…now my daughter is 10. It’s sort of funny to think about all the stuff that I was worried about when I was pregnant in light of the stuff that I’m worried about now. But, yeah, I mean, my guess is, you know, I will keep updating the book. Yeah, stuff happens in science.

Dr. Fox: Wait, so who recorded for the audio book, “The Foreword”?

Emily: I don’t know. It was some guy.

Dr. Fox: Oh, God.

Emily: Some guy.

Dr. Fox: Oh, Lord, you couldn’t get like James Earl Jones, or at least someone like with a cool voice? Morgan Freeman would be reading the part of Nathan Fox. Yeah, that’d be awesome. Oh, my God. Love it. Wow. So tell us about your new book that’s, I guess, coming or just came out based on when this podcast drops, “The Family Firm”?

Emily: Yeah. So “The Family Firm” is the kind of third in the series. There was “Expecting Better” about pregnancy. There’s “Cribsheet,” which is about kind of early childhood and “Family Firm” is about kind of decision making in the school years. And it has some of the same kinds of elements of the “Expecting Better” work. So there’s a lot of stuff about data, although this time looking into data on kind of older kid questions. So things about school or extracurriculars, kind of nutrition for kids, sleep, how kids learn to read, those kind of questions. But there’s also a big component of this book that’s about decision making tools and sort of recognizing that, you know, when you start being involved with parenting or with kids, there is a substantial element of logistical manager that you adopt. The book sort of tries to help people think about how can you make unexpected decisions in a way that is structured and helps you make the right decisions and also sort of how to think deliberately about crafting the schedule and the lifestyle that you want have with your kids so you don’t sort of wake up to find that your life doesn’t look like the way that you hoped because you signed up for too much extracurricular ice hockey.

Dr. Fox: It seems to me like there’d be of the three sort of time periods, you talked about pregnancy, early childhood years, and then all the others, that this time period in this book would have probably the least amount of hard data to go by. Correct?

Emily: Yeah. I mean, it’s complicated because I think that there’s data but it very rarely is directly the answer to your question. So I think some of these other times it was like, “Okay, we want to know, like, you know, like, what happens when you get an epidural?” and like then you like [inaudible 00:40:10], like look into it. And there’s some data and it kind of answers that question. Here, you know, there’s some data about what makes a good school, but that’s not the answer to like, “Should my kid go to this school or this other school?” Right? So I think much of the work of sort of this period of life and much of the work of the book is to say, “Okay, like, what is the right decision framework such that you know where to plug the pieces of data in that are relevant while recognizing that no one piece of data is really going to kind of answer your question the way it maybe it did when earlier on because everyone’s questions are different and they’re all kind of complicated?”

Dr. Fox: Got it. What are some of the real exciting topics that you put in the book and you’re like, “Oh, this is great. I’m so happy I get to write about this.”?

Emily: The thing I found the most, like, just purely interesting is the stuff about how we teach reading. So when you teach kids to read there is a question about whether reading should be taught with like a phonics base. So where you say like here are the sounds and letters and here’s how they come together, that sort of like Bob books, Mat-Sat approach, you know, Mat-Sat, whatever. Or do you do you kind of teach with what people call a full language approach where you read more interesting text initially and you, kind of, I don’t know, you teach kids more to like recognize words or to sort of think about whole language and you focus much less on the phonics piece. The phonics is a sort of like traditional way to teach. And then there was some like movement in some period like the ’80s and ’90s to sort of teaching this whole language way because phonics is boring or something like that.

But it turns out that actually phonics is like infinitely better than this other thing. And I think part of what was so interesting for me in that piece was to recognize how we can compile the data to understand that that’s true. And I’ll tell you one sort of small piece of that, which is, when you as an adult read, the way you perceive yourself to the reading, is that you’re you perceive yourself to be recognizing words and just like reading a lot, like you don’t perceive yourself, presumably to be sounding out words as you read. And that kind of leads people to think, “Okay, well, that’s how sophisticated readers read, they like read by recognizing all the words.”

But in fact, when you look at people in brain scans and you look at how they read, that’s kind of true for words that are up to about eight letters that you’re typically sort of recognizing the word, but actually, for longer words, even words that you that you know, you are chunking them in your brain as you read and effectively like sounding them out. Of course, you’re doing it so quickly that you don’t perceive that. But the idea that somehow, ultimately, adults read by recognition that turns out not to be true. And once you recognize that, it then seems sort of clear why it would be valuable for people to learn phonics because actually you’re always going to use a phonics in the way that you read. So there’s a bunch of different pieces of evidence that kind of come around to support that general view. But I really like these kinds of findings where you put a bunch of stuff together and then there’s like sort of an aha moment.

Dr. Fox: Wow, was there anything that was really controversial that you were writing about or that you thought you would get a lot of maybe pushback on?

Emily: I’m always surprised at the things that people push back on in the books.

Dr. Fox: Right. Like sushi.

Dr. Fox: Like sushi. Exactly. I don’t know. So, you know, there’s a bunch of stuff about, you know, writing. I read a lot about sort of what the research says on schools. And usually that’s a hot topic. So my guess is there’ll be at minimum some discussion about that. But I think, you know, most of the data here is probably not quite controversial in that way. But I don’t know. We’ll see.

Dr. Fox: Well, I look forward to reading it. I think it’s…

Emily: Thank you.

Dr. Fox: Mostly just to see all of the mistakes I made over the years. You know, as my kids are past that point then it’s like, “All right, where did we go wrong? Let’s see, what do we have to, you know, ask their permission.”

Emily: Too much ice hockey.

Dr. Fox: Oh, yeah. And did you get into a lot of the CTE and all that stuff with the brain…?

Emily: I do talk about brain stuff. Yeah.

Dr. Fox: Yeah, protection for the brain.

Emily: It turns out like soccer. Yeah, protect kids brain, yeah, totally you need that. But it turns out like soccer is quite bad for your brain because of the headers.

Dr. Fox: Right, and you don’t tend to wear helmets.

Emily: Right. And that’s true. You don’t tend to wear helmets.

Dr. Fox: Excellent. So what’s next for you? What do you got coming down the pike now that you have all this stuff coming out in 2021? What’s next?

Emily: I don’t know. I mean, you know, I’ve been spending a lot of time on the newsletter/blog. And you know, I think that that will continue to be a big part of what I do, but I don’t know. People ask if there’s another book. I don’t have any other books in the works at the moment. I guess you never know.

Dr. Fox: You never know. Awesome. Emily, thank you so much for coming on the podcast. I love having you on as a guest. It’s great to talk to you. I love reading what you put out and my listeners really do as well. I can tell because I know how many people listen to each of the podcasts and yours are always at the top of the list. And there’s a good reason. You’re really good at what you do.

Emily: Well, I’m really excited to get to talk to you. So thank you for having me.

Dr. Fox: Thank you for listening to the “Healthful Woman Podcast.” To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.