“Expecting Better: Dos and Don’ts in Pregnancy” – with Emily Oster

Dr. Emily Oster, author of “Expecting Better” and “Cribsheet,” explains what she has learned in her research and writing about pregnancy. She and Dr. Fox discuss common advice and misconceptions regarding pregnancy and data shows pregnant women should do.

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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. Okay. We’re here with Dr. Emily Oster. Welcome back to “Healthful Woman.” So happy you could join us again.

Dr. Oster: Thanks for having me again.

Dr. Fox: Wonderful. And as we were talking about before, we’re going to talk about something other than the coronavirus because, you know, that’s so old news.

Dr. Oster: We’re tired of it.

Dr. Fox: It’s taken over everyone’s lives, but, you know, listen, as I know for my day job, there are women who are still pregnant and they’re getting pregnant and all the same questions come up, and it’s important to go over that in addition to just talking about Corona.

Dr. Oster: I totally agree. Yeah. One of my friends just emailed me to be like, “I’m pregnant with twins,” and I was like, “Okay, yeah, life goes on.”

Dr. Fox: So, for our listeners, Emily Oster has been on the podcast a couple of times. You are a writer, you’re a parent, you’re a Ph.D. in economics, but the focus here is one of the books you wrote called “Expecting Better: Why the Conventional Pregnancy Wisdom Is Wrong–and What You Really Need to Know,” first in 2013, and revised a couple of times, and a bigger revision expected to come out in January of 2021, correct?

Dr. Oster: Yeah, exactly.

Dr. Fox: Fantastic. So, just for our listeners, and how did you even get into the pregnancy writing business at first? I mean, you’re an economist.

Dr. Oster: Yeah. I mean, I think the sort of short answer to that is that I got pregnant, and I found myself asking a lot of the questions that I think many pregnant women ask, which are, you know, I’m trying to make some decisions about my healthcare, my behavior, you know, should I have a cup of coffee? And I am a person who likes to do research and my economic stuff is mostly sort of health-oriented, so I found I was doing just a tremendous amount of research into the kind of medical or public health aspects of pregnancy kind of in service of my own pregnancy. To be frank, I got a little frustrated with a lot of the books, a little bit with my doctor, but more just with the kind of books and information that was out there. And so, I was one of those people, I was like, “I’m going to write. I’m going to do this. I’m going to write a book,” and then I did.

Dr. Fox: It’s so interesting that you said that because the way I sort of heard you is… One of my patients said, “Hey, have you heard of this book ‘Expecting Better’?” And, you know, I said, “No. Like, I don’t read pregnancy books that are sort of out there because I…you know.”

Dr. Oster: Written by an economist, as you are, in fact, an actual doctor. That’s okay.

Dr. Fox: No. I said, “No,” and she said, “I think you’ll really like it because a lot of what she writes… It sort of sounds like you,” is what she said. And so, I said, “Okay.” So, I read it, and I was like, “Yeah. This is great,” and then because the pregnancy books out there frequently are not evidence-based. They’re really just someone saying their opinion or saying what people have said. And if you look through them, like, people say, “Oh, my book said this.” I’m like, “No, your book is wrong,” and it’s unfortunate. I mean, these things are written to sell. They’re not written, you know, to give people evidence-based advice, but the fact that you did it that way was really pretty cool. And as we’ve said before the podcast, I emailed you [inaudible 00:03:14], like it was great. And it’s been an excellent find for me, so to speak, and what a good relationship, but I’m curious what you said about that. Has this given you less confidence in sort of the medical profession, the fact that it took a Ph.D. in economics to just get this right and put a good book together for pregnant women? 

Dr. Oster: No, I don’t think so, actually. I mean, I think in a sense, like, the problems are not so much with the medical profession as with the kind of way that a lot of medical research is done, which I think you could say is the fault of the medical profession, but actually those are often not the same people. And so, you know, a lot of the stuff I was frustrated with was, you know, this isn’t a very good public health study, but that’s not really the fault of doctors. That’s like a fall down in the statistical training we have in a lot of fields. And then I think the other piece that was sort of interesting to think about is some of these books that I read, it’s not that they were wrong, or…I mean, some of them were wrong, but it’s not that they were all wrong. I think that the piece that was really frustrating was they didn’t explain why. The thing that I try to do in the book that I think is a more unusual piece is not so much what is the recommendation, but where does the data come down, but trying to help people walk through, like, why some data is more convincing than others and why you’d come to these conclusions, and I think that is something people had not tried to do. 

Dr. Fox: Yeah. And also I think some of it is that, you know, recommendations are generally very…they have to be concrete, sort of black and white. “You should do this. You shouldn’t do this, you know. Take up to this amount, but not more than this amount,” because people need some guidance. Problem is, you know, the decision of where to draw the line, when to say yes, when to say no, how much to allow, how much not to allow is not always based on, “Well, we know that under this amount is safe and over this amount is dangerous.” It’s sort of like, “Well, we have some evidence that it might be bad, so let’s just sort of pick something.” But, you know, for someone, for an individual level, people might find like, “Well, for me, this is more important to me,” or, “This is more necessary to me than somebody else.” Like, for example, you know, we’ll talk about like caffeine. It’s like, okay, you can tell someone, “Don’t have any caffeine,” and that’s fine, that’s easy to say. But for someone who really doesn’t have it, doesn’t need it, doesn’t care, that’s easy. But what if someone gets horrible headaches if they don’t have caffeine? So, maybe their numbers should be different because they’re going to sort of suffer if they don’t take it, and the recommendations have a hard time with nuance, and I think that if you understand where it comes from and what is the data, what is the real risk, where are these numbers derived from, you can allow for more nuance and individualization with these recommendations.

Dr. Oster: Yeah. And I think it’s also helpful for people to understand, like, why are we concerned about this in the first place? And I think that’s a piece that often is also not always well-explained, you know. Are you worried about miscarriage? Are you worried about birth defects? Are you worried about high blood pressure? Are you worried about you getting fat? Like, you know, what exactly is the reason for this? And then I think that that’s often also helpful for people to think about how does this recommendation actually apply, like, to me?

Dr. Fox: And I’m curious, so you wrote this book. It’s wildly popular, you have a website, and you have a newsletter. How much, I guess, questions are you getting people saying, “Hey, give me advice. What do I do?” And sort of in the world that crosses over into medical advice versus practical advice, A, how much do you get, and B, how do you feel about answering those kinds of questions?

Dr. Oster: Yeah. I get a lot of emails, and the moment I’m getting a lot of emails that are, like, can you help me make this decision, which is actually much more in my space. I feel very comfortable with that, but I do get a lot of sometimes, like, super in the weeds medical questions, like, where did you learn about this particular genetic variants? And like did the…? Which I have no idea about, and most of the time with those, I will just tell people, “I’d like you to talk to your doctor about this. I don’t know anything about this.” Occasionally, people ask me something that’s a little more general. One of the things that the book has done for many people is given them more of, like, even footing to have conversations with their doctor. And so, rather than, you know, not like it doesn’t…obviously, it doesn’t replace the doctor, but just, you know, if I understood more about prenatal testing, it’s much easier to quickly get to a place where we can talk about it more easily. And so, I think often people are asking me, basically, “I was diagnosed with this. I don’t really understand it. I want to understand more about it before I go, like, talk to my doctor about it.” So, sometimes I’ll send them UpToDate. I’ll send them, like, you know, UpToDate abstracts and say, “Look, you know, this is a little technical, but you might…” It’s like, you know, the patient information, and those tend to be pretty helpful, I think.

Dr. Fox: Right. Right. UpToDate is a website that has a lot of medical information. Doctors use it a lot. It’s a very good resource, but they also have in it sort of this is a good summary to give to patients who aren’t doctors. And so, that’s available and you have to sign up to be a member of it to have access, but yeah, that’s very good. Totally on-board with that. This is one of the reasons I’m doing this podcast. I don’t get paid for this or anything, but it’s the same thing. If someone is about to talk to me about whether they should do a CVS or amnio, like genetic testing, you know, there’s amount of background information they might not have, and in order to have a more high-level conversation, if they come in with more knowledge about it, we’ll have more time to talk about it. So, for example, they could listen to the podcast and then come talk about it and it’ll be a much more productive conversation. And I do think your book has opened that up for a lot of women, a lot of families, which is fantastic. Have you gotten pushback from doctors or whatnot saying, you know, “You’re in the wrong space,” or one of those types of things, “Who do you think you are?” Have you gotten any of that?

Dr. Oster: Yeah, sure. I mean, I got a lot of that when the book first came out and I think, you know, partly because, like, a lot of the press we did run in the first part of the book was around alcohol and the idea that you…you know, which is a whole can of worms, which could get open or not as you please, and I think it’s actually a pretty small part of the book, but kind of riled up not so much doctors actually, but the kind of the medical community and some advocacy groups and so on, and there, I got a lot of pushback. It was like, you know, “This person is not a doctor.” Like, “Why are you listening to them? They just sound, like, random economists.” And I still get some of that. Now that I have two books, you know, I get like…

Dr. Fox: Right. Now you’re no longer…yeah.

Dr. Oster: Now I’m just like a writer, right?

Dr. Fox: Right. You’re not a random economist. You are a specific economist.

Dr. Oster: Right. I was like this very specific.

Dr. Fox: How have you handled…? I mean, I’m curious, just personally, you’re an economist, you’re a Ph.D., you’re working in university and now you’re sort of a national figure. How have you handled that, just in general, the fame, I would say, of this?

Dr. Oster: The fame, the deep-seated fame of writing? Yeah.

Dr. Fox: Yeah.

Dr. Oster: I think that you may overstate. I may be more famous in your circle than in the broader world. I will say…

Dr. Fox: I guess that’s fair.

Dr. Oster: Yeah. I think the piece that’s still kind of weird is that I’m still… I mean, most of the time, I’m just like I’m a professor and this is sort of… It’s become a much bigger part of my professional identity, but it’s still like a little bit of a side project. I mean, or at least, you know, until recently, just gotten really involved with COVID, but until recently this was more of a side project, and there was this best encapsulated by this moment, so I sit on the tenure promotions committee at Brown, which is, like, a pretty high-level committee that reviews appointments at the university level. And at some point, one of the guys that I sat on was like, you know, “My daughter is having a baby.” I was like, “Oh, that’s so great. Congratulations,” and he was like, “And I was visiting her and she said that she was reading a book by someone at Brown and it was you.” And I was like, “Yeah.” He was basically just like, “What is that?” Like, “What are you doing?” And so, there’s like this…

Dr. Fox: What have you been writing about?

Dr. Oster: Yeah. There’s like this sort of weird separation. Sometimes I’ll go do, like, book talks and people will be like, “So, like, are you still a professor?” I’m like, “Yeah, like, most of the time.” And so, it’s just they’re so separate that it just feels like they’re really separate.

Dr. Fox: Right. And when you’re a professor, I mean, none of your courses are related to this. You don’t teach a course on…yeah.

Dr. Oster: No. My research is not. Yeah, no, no. I mean, I teach a course on statistical methods called the complied methods, and my research is about statistical methods and a little bit about behavior, but none of my research is about this stuff at all.

Dr. Fox: It’s all good. I love it. So, you know, keep doing it. I did want to jump into some of the topics you cover in the book. Obviously, the better thing to do is to read the book, but just to give our listeners a flavor of sort of the things you write about and what kind of opinions you might have. And you did organize the book sort of chronologically through pregnancy, you know, conception, first trimester, second trimester, and so forth. Which part of pregnancy was the hardest for you to research? Was it the early pregnancy stuff or more the labor and delivery stuff or something else?

Dr. Oster: It’s more the early pregnancy stuff. So, I think one of the advantages of the labor and delivery stuff is a lot of the evidence is from randomized trials. So, you know, there’s a little bit of a challenge of figuring out which is a good trial, but, honestly, it’s not that hard because there’s usually, like, one and it’s really big and it has a special name. That piece wasn’t as hard. It’s still hard to write in some ways, and there was some data to produce, but it was actually more straightforward. The early stuff is harder because the evidence is less good, more sort of nuance. There’s more issues with causality, and so that part just took…it took longer to research. It took longer to figure out what’s going on and then it took longer to kind of figure out the right way to express it to people, to present it.

Dr. Fox: Right. And I know you mentioned the stuff about alcohol was pretty controversial, I guess. Was there any other aspect that either you knew upfront would be, you know, controversial, or not well-received, or something that maybe surprised you?

Dr. Oster: So, this is going to sound so stupid of me, but, like, I was surprised by how people reacted to the alcohol thing because I’m like a total dummy. And the thing is, like, I knew a lot of…it was like a good share of doctors who will tell people it’s okay to have the occasional drink, and kind of, like, those are the people that I knew, and so I was surprised at the vitriol of this. I think most of the other stuff was fairly even. I didn’t get a lot of pushback or at least not stuff that I was surprised by.

Dr. Fox: In my own practice, I could say when I go through the dos and don’ts of pregnancy in the first trimester I can tell you that the thing that always seems to surprise patients the most when I tell them is, “You can eat sushi,” and they’re all like, “What? What?” And then they’ll always say to me, “You mean raw fish?” And I’ll be like, “Yeah. Like, I know what sushi is, you know, if we’re talking about the same idea.”

Dr. Oster: You don’t mean, like, the egg, the weird egg thing?

Dr. Fox: And it’s like more than any… Like, literally, if I told them they could do crack, they’d be like, “Oh, yeah, I get it,” but, like, sushi, like, “Oh, my God, I can’t.” And then so that’s where I wanted to start. Let’s start with the fish. Why does everyone freak out about fish in the first trimester?

Dr. Oster: I guess there’s, like, two things that people worry about. So, one is that they worry about salmonella and the idea that, like, sushi is like the thing that makes you really sick. And then I think somehow part of it is that also sushi is sometimes this high mercury fish, and so I think those have been… Like, somehow sushi has been tarred with both brushes and has just become this thing that also is just like every pregnant woman knows, like, “That’s it. You can’t have any sushi.” And I think that’s why people find it so surprising when you’re like, “No, actually that’s…” you know. Maybe you shouldn’t eat… Like, don’t a shark. Shark is probably not a good idea, but like some sushi is fine. [inaudible].

Dr. Fox: Yeah. And the interesting thing is, with the mercury business, it’s totally related to the type of fish you’re eating, not whether it’s cooked or raw. I mean, like shark is high mercury, whether you can grill it or eat it raw, it’s still going to have high mercury. You can’t cook mercury out of food, and so other than shark, and swordfish, and king mackerel, that’s really it. I mean, tuna has a little…so we’d limit the tuna, but the raw or cooked has nothing to do with. And I do think there’s been some… It’s got conflated that someone is like, “Oh, since you can’t eat mercury, you can’t have any fish,” but something like, you know, salmon, and whitefish, and shellfish, it was like, “There’s no mercury in that or almost no mercury,” and so it’s not really an issue. And the raw cooked is a food poisoning thing, and if you’re really worried about, you shouldn’t eat it when you’re not pregnant either.

Dr. Oster: Right. Yeah. I mean, I think that’s the point I was having. It’s like, if you think that the sushi you’re eating has salmonella, like if it seems like dirty and it smells weird, you shouldn’t eat it, but like, you should never eat that. Like, don’t have your husband eat it, you know. This is like not…that’s not… Like, you should be eating. Like, if you’re going to eat raw fish, you should be a little more careful about where it comes from all the time.

Dr. Fox: Right. And it just stings to, you know, get food poisoning when you’re pregnant. Sound like it specifically causes birth defects or miscarriages.

Dr. Oster: Just very unpleasant. Just very unpleasant.

Dr. Fox: Yeah. And I always remind me, you know, there’s like a whole country where people eat sushi all the time and Japanese seem to be doing okay, and it’s just like I don’t know why everyone is so worried. Here, I am, go to a clean place. I wouldn’t meet off a street vendor, but again, I would say the same thing to anybody. Nothing to do with pregnancy. So, that’s really a big one in my practice. I’m, like, known as the guy who allows sushi as if I’m some, you know, crazy renegade doctor.

Dr. Oster: You’ve got a renegade…exactly, like this nut job. Go to the nut job, and let’s eat the sushi.

Dr. Fox: Yeah, that’s me. I’m going to put my business card, “Come to me. I’ll let you eat sushi.

Dr. Oster: Totally sushi. What do you tell people about deli meats?

Dr. Fox: So, deli meats. You know, deli meats is interesting because the fear for deli meats is, as you know, a specific type of bacteria called listeria, and that’s also why they say don’t eat unpasteurized dairy products. And, you know, there’s various things that might have listeria. Listeria is a weird bug because it’s been in so many things over the past 20 years. There was an outbreak in hummus. There was an outbreak in cantaloupes. There was an outbreak in ice cream.

Dr. Oster: Bean sprouts, ice cream.

Dr. Fox: Yeah. And there was an outbreak in deli meat, like, 20 or something years ago, and so because of that, they’re like, “Don’t eat deli meat.” You know what I tell women is, number one, the chance is very, very, very low. Number two, all right, listen, maybe don’t eat the stuff that’s packaged and sitting around in the supermarket shelf for six months, like, all right, get fresh deli, you know, like sliced pastrami or something, and that should be fine. And if someone is really…you know, they love it but they just want to be a little bit extra paranoid, which is fine, God bless, like microwave it or heat it.

Dr. Oster: Microwave it.

Dr. Fox: And if it’s hot, then the bug is killed. But I don’t discourage people from eating proper deli sandwich, you know, corned beef on rye. Like, the chance of getting listeria is really no different from anywhere else. I tell people, if you hear on the news there’s an outbreak of listeria in something, listen, you know, find out what it’s in and don’t eat that. Otherwise, it’s really not such a big issue. And a thing to get back to also, which is true sometimes for me than sometimes for the sushi is, you know, sometimes the people who say, “Oh, I want to be extra cautious,” it can actually be counterproductive because fish are so good for you in life and in pregnancy. And if someone’s like, “Well, yeah, the way I eat fish in my diet is through sushi,” and then they stop eating it, it’s probably bad that they stopped eating sushi, not just neutral. And so, it’s something if they want to be cautious, all right, eat cooked salmon, but fish is good for you. And so, people have to be careful that their paranoias are not being counterproductive. If it’s a paranoia that’s harmless, you know, God bless, we all have them, but it’s important not to go overboard with these things.

Dr. Oster: When “Expecting Better” first came out, somebody wrote something that was like, you know, “You say deli meats, like, are okay and the risk of getting listeria is very low, but I got listeria, and I miscarried,” which, of course, you know, can happen and is tragic, they didn’t get it from deli meats, they got it from something else. But then they said, you know, in my second pregnancy, like, “It is important not to tell people they can take chances. In my second pregnancy, I only ate packaged foods. Like, I only ate packaged Doritos.” That’s also not good for you. That isn’t the reaction.

Dr. Fox: A full diet of Doritos and bottled water. 

Dr. Oster: Yeah. Like, that isn’t the reaction you want to have either, so there’s this sort of tension between kind of in the effort to be careful you may actually take some other kinds of risks.

Dr. Fox: Right. And I think that alcohol is a little bit different. I definitely want to talk about that because what basically you concluded in your book, which is basically what all the evidence shows, is that we know that high amounts of alcohol are bad for the baby, don’t do that, but there’s a ton of evidence that a very small amount of alcohol, and what defines very small we can get into, has no long-term or short-term effects on the babies. And you said so fine, and that’s what it is. And I think people went nuts over that, and I think that part of it is because the party line, like if you look at the national societies, like the American College of OB-GYN and, you know, all these people that put out recommendations, they say, “We know that that’s the case, but since there’s really no upside to alcohol, you should have none during pregnancy.” And so, that sort of the recommendation on the books is no alcohol during pregnancy, but that’s mostly because there’s no known benefit to it, not because anyone thinks that taking a half glass of wine a week is going to cause great harm.

Dr. Oster: I think that’s right. The response to this struck me a little bit, it had a lot of different pieces, and so I think, you know, there were definitely people who took issue with the evidence either in ways that I thought were a little bit confusing. So, there were the people who would cite studies to me that, like, either we’re just made up or didn’t really have, you know, any strong basis in reality. I think that you always get some of that. You know, and then there was a lot of pushback just around people saying, you know, “Look, we can’t tell people, even if we all agree that having a little bit is fine. If we tell women that they can have a little bit of alcohol, they’ll have a lot, and it’s better to just tell them not to have any because we know that not having any is safe, and we know that having a lot is risky, and if we give them a little bit of permission, they’ll kind of go…they’ll go too far.” So, I actually heard…I heard that reaction, like, quite a lot from a policy standpoint, so I think is a sort of slightly complicated, it’s a little disrespectful, but also is sort of complicated, even from a policy standpoint.

Dr. Fox: Right. Because it may be the opposite, and maybe if you only give people two choices and one choice is zero and the other choice is whatever, then they won’t realize that there’s a difference between having a half glass of wine a week or three glasses a day, unless you put that up. You know, what I typically get is, you know, the data is…actually it’s a lot of data. I mean, they’ve done long-term studies. They look at kids when they’re age 7, age 10, age 15, and basically, in all of these studies, when women drink, you know, what’s called less than a certain amount, it typically that ends up being about less than one drink a day or nine drinks a week, somewhere in that range.

Dr. Oster: Yeah. Something in that range. Yeah.

Dr. Fox: Yeah. It depends on the study. They’ve never found any adverse effects on the baby/child when the woman drinks less than that amount, which is great. I mean, that’s really good evidence in that sense, and what some people will say, “Well, okay, you know, maybe there’s, like, instead of the IQ being 120, it’s going to be 118,” or, “Maybe instead of, you know, getting it to X college, they’ll get into one less college,” and that’s not something you could tease out in a study. And I tell you, that’s possible. I mean, theoretically, it’s possible, but it’s not really known to be like that with any other teratogen, you know, bad thing in pregnancy type of thing. So, it just doesn’t make sense to me. And so, what I tell women is we know that high amounts are bad. Everything that we’ve seen shows us that low amounts are good, and I ask, like, “What are we talking about here?” And she goes, “Well, I want to have half a glass of wine with dinner every three weeks.” I’ll be like, ” All right, you know, like, can I promise you 1000% there’s 0 risk?” No, but basically, everything we know says there’s no risk to that. I don’t have an issue with it. I tell them the party line is not to have any. I tell them what is recommended, but I tell them, “I don’t think it’s a big deal in that sense,” and, again, people, they still seem to be bothered with it as much as they are with the fish.

Dr. Oster: Somehow most people get very strong cravings for something like that, and you just, like, can’t stop thinking about it.

Dr. Fox: Your analysis, the alcohol was very reasoned. It was reasonable, and I think it… And the people who write about this, even though once they make their recommendations, don’t even disagree with you. They say, “Yeah, that’s what it is,” but either because the reason you said that it’s just not wise, or because we can’t prove for sure there’s no tiny effect, or just because I think it’s not worth it, for whatever reason everyone sort of just says, “No alcohol whatsoever.” And again, I think most women are fine with that, and they’re just like, “You know what? I don’t need to deal with this,” but some, it’s important to them for whatever reason, either from a social reason, sometimes a religious reason, and they’re like, “My religion, you know, there’s wine in certain ceremonies,” or just it helps them feel relaxed, you know, whatever, and that’s… I try not to make people feel too guilty over these things because the vast, overwhelming, like, that this is not going to be an issue.”

Dr. Oster: Yeah. I also think there’s a sort of complicated messaging piece here, which is like we’re sort of messaging. We’re sending this message, and I think the message is being listened to by sort of certain people who are already probably taking a lot of other precautions and sort of thinking carefully about this, you know, all kinds of other stuff, and the message is probably going…is not going as much to groups that maybe need to hear it more. So, I actually think a fair amount of the sort of very problematic alcohol exposure happens before people know they’re pregnant. People who got pregnant, like, basically didn’t realize you were pregnant or weren’t trying to get pregnant. It was accidental. You know, they’re drinking a lot in the first week. They don’t find out until a bit late, and so the kind of…you can say whatever you want about alcohol and pregnancy if a lot of the exposure is happening before people know they’re pregnant then, you know, that messaging is not very helpful.

Dr. Fox: How is your research on caffeine? Were you surprised by any of that compared to the messaging that you got when you were pregnant?

Dr. Oster: Yeah. I mean, so the messaging on my caffeine was, in some ways, like, it was more…so the messaging on alcohol I didn’t necessarily agree with, but at least it was very consistent. The messaging on my caffeine, it was like every book said a different thing. It was like, some just, like, “No, no coffee at all.” Some was like, “Well, two cups is fine.” Some was like, “Three cups is fine, you know, one cup is fine,” then make you measure how big it is, you know. And so, always, when you come across those kinds of things, you got to wonder, like, “Where is this coming from? Because it’s really that…like, you guys must all not be reading the same pieces of information. And, you know, I think there was caffeine. It was very helpful to kind of take a step back and say, “Okay, what are you worried about?” Okay, worried about miscarriage primarily.

Dr. Fox: Right. But that’s a big one because what you said before, people don’t always know what we’re worried about. They think…like alcohol, you’re not worried about miscarriage. You’re worried about, you know, like, birth defect or brain development, but caffeine, it’s not that. You’re not worried about any of that. You’re just worried about maybe it’s going to cause a miscarriage. So, this is a different outcome.

Dr. Oster: And also, you know, that has sort of implications for how you think about, you know, the third trimester is very different from the first trimester in that standpoint. Really, we’re talking in caffeine about the first trimester. This is a place where you kind of totally geek out as a person who like causality because actually, like, one problem with all the data is that, you know, women who drink a lot of caffeine tend to be older, and so they’re more likely to miscarry for that reason, but that’s not so interesting. That’s only moderately interesting. But then there’s actually this concept with nausea, which is that women who are nauseous are less likely to miscarry for various reasons. It appears to be correlated with continuation of pregnancy, but they’re also much less likely to have coffee because coffee is, like, not appealing if you are about to vomit all the time. And so, you actually end up seeing sort of, like, the nausea that’s kind of correlated with both of these things. It’s not obvious there was just any link more or less at any level between caffeine and miscarriage.

Dr. Fox: Right. And in this study…yeah. In this study is you’d have to have mega doses of caffeine to slightly increase your risk. I mean, you’re talking like 8, 9, 10 cups a day in order to even slightly increase your risk of miscarriage, or mostly right there.

Dr. Oster: No, people are like, you know, “Is it okay? Like, I’d like to have a half a cup of coffee with a lot of milk.” Like, they say, “I can’t…I really would just love to have a half a cup of coffee with a lot of milk in the morning.” I was like, “Oh, my God. Yes.” Like, “Yes, of course, like, you should definitely do that.”

Dr. Fox: Right. And isn’t this sort of the area with the nausea and the caffeine where you threw your mother-in-law under the bus?

Dr. Oster: I’m sure there’s many areas where I threw my mother-in-law under the bus. My mother-in-law is a wonderful lady. She’s actually downstairs in my house right now taking care of my kids. But she was actually very nauseous and she was very sick when she was pregnant, and she also has a lot of crazy theories about data.

Dr. Fox: What are you telling people, or what did you tell people about cats, and gardening, and toxoplasma?

Dr. Oster: So, there’s this concern with cats that you will have toxoplasmosis, which can cause some significant problems, and, you know, it is true that cats can have that, but it turns out actually like having a cat is not particularly linked to having this in pregnancy, I think, partly because people are often exposed earlier, and partly because it’s mostly…if your cat is eating a lot of raw outdoor meat, then actually there is some sort of elevated risk in outdoor yard work gardening of this particular… I mean, it’s still small. You know, this is a relatively small risk.

Dr. Fox: When you spoke about the…or wrote about the second trimester stuff, things you put in, I really loved. One of them was this idea of you’re not eating for two, and the second thing was about exercise, and I’m a big fan of keeping your weight in check as best as you can and exercising a lot. And did you find a lot of data on this or just that, you know, there’s no data that it’s harmful, so you should just do what’s healthy?

Dr. Oster: There is some data on the exercise piece where… You know, again, it’s the place where you want to kind of figure, okay, like, what are you worried about? Right? So, I think something people are worried about is, like, you know, “If I run, the baby will fall out,” or something. This is not the way it works. So, you know, you could sort of…like the basic biology would tell you, you know, that’s okay. And then with people, I mean, I was…like, I do a lot of running, and so I was particularly interested in the running piece. And they’ve actually done these things with elite athletes looking at, you know, how is the blood flow to the placenta compromised when you’re really running hard? You know, not like totally jog, but really trying to train for something. And, you know, there’s kind of short-term…you know, in this sort of short-term in the most extreme moments, the blood flow is slightly lower to the baby, but doesn’t seem to be like not in a way that’s clinically relevant. And so, I thought that’s something, like, in some ways, we were able to measure pretty well. There is this issue, I don’t know how much, like, that people’s ligaments get a bit looser.

Dr. Fox: Yeah. Yeah.

Dr. Oster: And that you can then get, which I definitely…so at the end of my second pregnancy, I pulled a hamstring.

Dr. Fox: There’s also an issue with people’s balance is different and their whole center of gravity is different, so people who run or do sort of exercises, a lot of movement, they tend to move a little bit differently when they’re pregnant for many reasons, which makes sense, and the second thing is the joints become a little bit more lax. And so, there is a slightly higher risk of injury from, you know, pull things and strain things, not so much, like, broken things unless you fall, but those things do happen, and so we tell people to be a little careful about that. Same thing with people who do a lot of yoga. Sometimes they have to be more careful when they’re pregnant because they can stretch more than they normally would, and sometimes they can overdo it. But again, that’s more of, like, a musculoskeletal type thing. It’s not really…they’re not hurting the baby from it. It’s just…

Dr. Oster: It’s not about the baby. No, I just couldn’t walk.

Dr. Fox: Yeah. That definitely happens.

Dr. Oster: I pulled the hamstring at, like, 37 weeks. It was like really bad.

Dr. Fox: Right. And remember, you know, at 37 weeks, most people at that point are 20 to 40 pounds heavier. Their center of gravity is different. They’re going to walk differently. They’re going to run differently, and it could be simply just that, but certainly could also be an issue with the joints themselves. And then probably you could write an entire book on this, but what did you find when you were looking up the idea of medications in pregnancy? You sort of put that in the middle of the book, and again, you could write a 1,000-page book just on medications and pregnancy and how crazy poor the data is on that, but what did you find?

Dr. Oster: I mean, I think mostly the data is terrible. Like, the sort of headline results here was just that the data we have on this is absolutely awful. It’s interesting the reasons kind of why it’s so bad, which is basically because we were trying to protect pregnant women by not doing studies on them. So, you know, we don’t want to include them in their studies because, of course, like, then they might be injured, and that’s considered not ethical. There’s actually some ethics people have now argued, “Look, it’s actually unethical not to do this.” You know, like when we don’t evaluate…you know, we don’t test SSRIs in pregnant women. Well, now, like, there are a lot of pregnant women who need to…you know, have been relying on antidepressants, who feel like maybe this is not safe to take, that’s an ethical issue.

Dr. Fox: Notoriously pregnant women and children are excluded from studies, and the problem is there are pregnant women and children who we need to know what to do with them. And so, I mean, I don’t know why it’s the fear the researchers have is they have to… There’s so much more regulation that comes into place in their study if there’s a fetus involved because anytime you do a study where you’re doing something experimental, there has to be an oversight on safety, and that’s very, very hard to do. But if you’re like, “Okay, I’ve got a person. He or she can come in, we can look, we can do a blood test. We can evaluate them, decide if everything is safe and move on,” how do you evaluate the safety of the fetus? Like, who’s going to do that? Are you going to do it during pregnancy? Are you going to do it after birth? I mean, who is responsible?

Dr. Oster: You follow them for like 15 years. What if it’s later? Like, you know, who is…? Yeah.

Dr. Fox: It’s almost just not worth it for the researchers. Forget about the ethics of it. They’re just like, “I can’t do this. It’s just not possible.”

Dr. Oster: It’s too much work. Yeah. I mean, I think, you know, in the end, when we come down with the drugs, there’s basically a few things that kind of seem like they’re pretty safe, some antibiotics, which I think we’ve decided we have to evaluate, things like folic acid, Tylenol, so basic stuff that is categorized as pretty safe. There’s a few things that are just totally off-limits, like Accutane. Like, I can never say the generic for that, but…

Dr. Fox: Yeah, isotretinoin.

Dr. Oster: …there are few things that are…yeah, exactly. There are a few things that are totally off-limits, and then most stuff is in this kind of vague intermediate category where, basically, they don’t have any evidence to suggest that it’s bad and we don’t have sufficient evidence to suggest that it’s okay.

Dr. Fox: Yeah. It’s hard. I mean, you mentioned SSRIs, and this is something that we talk about all the time.

Dr. Oster: And it has come out for you guys all the time. Yeah.

Dr. Fox: Yeah. I mean, you know, the problem is…and then people have tried to study this. I mean, obviously, there’s a lot of people who want to know the answer, but the best way to do this is to take, you know, let’s say 10,000 women, randomly divide them into 2 groups. Give 5,000 of them, let’s say, Prozac, and the other 5,000, give a drug that looks just like Prozac but has nothing in it. Nobody knows who’s taking what, and then you follow them through the pregnancy, and then after birth, you do, like, 10 years of neurologic testing on the babies. You look for birth defects, brain development. Just that. So, that’s a hard study to do for a lot of reasons. One, it’s expensive, two, it’s very hard to just tell people, “I’m going to randomly give you Prozac or not.” Like, that’s not what happens in the world. So, what they do is they look back at 5,000 women who took Prozac and they compare them to 5,000 who didn’t, and there’s a lot of problems with that as you know. One is, they’re not the same at baseline. The group who takes Prozac is probably more likely to be older. There’s probably a higher proportion of women in there who may be smoking, or drinking, or have other health issues, and so any difference you see could be due to that. And the other issue is, when we have women who are on Prozac, we test their babies more. So, if you find a little tiny hole in the baby’s heart after birth, you may not have even checked in the other woman, and so you don’t know if it’s really a higher rate. And the studies, the risk of birth defects, you’re talking about like 1%, and so I tell them, “Listen, the risk is probably up to 1%, but maybe 0. We just don’t know, and if you don’t take it, you may have other problems.” And so, it ends up being, I think, almost, I don’t know, counterproductive to have these studies that show some possible risk when it’s really unclear, and the benefit is huge.

Dr. Oster: Yeah. Yeah. And I think people are sort of left in this position where it’s like, “I really…” It was sort of, like, “Well, you should take it if you really feel like you need it,” you know, which kind of leaves women to… And not that you would say that, but I think that that is the message that women sometimes, at least here, and sort of like, “Well, like, I do need it, but I don’t want to risk my baby,” and somehow implying like, “Are you too weak that, you know, you have to take this even though it’s bad for your baby?” and I think that’s a very tricky effect.

Dr. Fox: Yeah. If we end up saying something that sort of either truly does or makes a woman think that we’re putting her against her baby, that’s a bad situation because…

Dr. Oster: That’s very bad.

Dr. Fox: And it’s also not even true because usually what’s good for her is good for the baby and vice versa. So, what I tell women about SSRIs sort of generally is the only people who really should stop it before pregnancy or during pregnancy are people who really…they never need it. Like someone got prescribed 20 years ago. They don’t even know why, you know. They’d be like…

Dr. Oster: Like, they have like a super low dose.

Dr. Fox: Yeah.

Dr. Oster: It’s just like it.

Dr. Fox: And you should tell them, “Listen, maybe speak to your psychiatrist or whoever if you try to go off it before pregnancy, see how you do. If you’re basically the same, fine. If you’re a wreck, then no, you should be on it because not eating right, not sleeping right, all those things are also a problem with pregnancy potentially.” And so, most women who are on it need to be on it, and there are some that don’t, but generally, I would say that’s the exception, at least in my experience of women I see, you know. Others may have different patient populations. I don’t know. I’m assuming that you went into the data on bed rest. It made smoke come out of your ears.

Dr. Oster: I mean, that was the place where I couldn’t…like I… Something like 20% of women are prescribed some kind of that. I mean, it’s a really big number, and then I was, like, yeah, like, “Okay, let me think about what are the things that you might be prescribed bed rest for?” It’s like everything, you know. It’s like suspected preterm labor, you know. It’s like a lot of different stuff that they prescribe bed rest for, and it’s not useful for any of them, but basically for almost no situation is it a good idea to prescribe people bed rest. I just couldn’t quite understand, honestly, just, like, what was going on there. I mean, I guess, then you dig in and you understand what’s happening, which is like for a large, you know, good share of women who go into preterm labor, so they have some threatened labor early on that then stops, for a good share of them, everything goes fine, and they make it to term or close to term. And so, if you put them on bed rest most of the time, they will do fine. And so, then that reinforces, I think, in the mind of them, but also of their doctor, like, “Okay, well, that was a good idea.” Seem like a good idea if you just lay down, stop doing so much, maybe the baby will stay in there. Oh, and then it worked. Okay, next time, I’m going to feel compelled to do the same thing again. And then, you know, what we get from the randomized trials is like, yeah, that’s true that they didn’t go into preterm labor, but neither did the people who we let walk around, and I think somehow then, that finding was not as quickly as it might have been sort of translated into nobody should be on bed rest. It sort of somehow got stuck in, like we’re still prescribing this a lot. I don’t know. You must have some instincts about why this is an appealing thing.

Dr. Fox: It’s an amazing thing. I mean, I did my fellowship 12 to 15 years ago, and during that time, I did a survey on this, which is actually the data you’re talking about, about how many people prescribed bed rest. One of those is one of the studies I wrote about this, and this is 15 years ago. And back then, we all knew the same thing, bed rest doesn’t work, right? And the data was exactly as clear then as it is now. And we knew this, but a lot of people are prescribing it, so I was like, “All right, let’s send a survey.” And we surveyed, you know, I think it was like 900 maternal-fetal medicine specialists. These are, like, high risk doctors, the highest trained obstetricians in the country, and so many people were still prescribing it for all these reasons that they all knew it wouldn’t work, meaning the responses were, “Yeah, we don’t think it’s going to work. Yeah. I’m going to prescribe it,” and I think that just…which is, you know, obviously, it’s totally disconnected. And I think that what happened is in sort of the history of medicine and even now, there’s some things we just can’t do anything about, and people, doctors included, are often very uncomfortable with the notion of there’s nothing I can do. Like, “It is what it is, you know. Let’s hope for the best,” and the people who are uncomfortable with that will say, “Okay, listen, I got to do something, so I’m going to prescribe bed rest, or I’ll give her this medication that I know doesn’t work. She’ll feel better about it. I’ll feel better about it. You know, something bad happens, she won’t blame herself. She won’t blame me.” Like, whatever it is, there’s something either overt or subconscious psychologically about the inability to just watch, you know. But if you tell them in this, like, women ask me, “Should I go on bed rest?” And I say, “Listen, there’s no evidence that it does anything.” I say, you know, “The studies aren’t perfect, so do I think you should be training for an Ironman right now while you’re in preterm labor? No.”

Dr. Oster: Probably no.

Dr. Fox: Yeah. I said, like, “You shouldn’t be running a marathon. I don’t want you lying in bed all day. The right answer is probably somewhere in the middle and no one knows exactly where in the middle.” So, I said, “It depends, you know. If your activity causes you a lot of contractions, probably it’s a good idea to back off, and then you feel perfectly fine, and then for you, it seems to be okay,” and, you know, I will see how it unfolds over the course of time. But people get very, like, “You have to do this. You have to lie in bed, ” and then, you know, there’s downsides to that. People get blood clots, they get constipated, they get depressed, they can’t work. You know, they need a babysitter. Like, there’s all these things that happen, and then when the baby is born, they’re totally, like, wasted and emaciated. They can’t take care of them. It’s just a disaster sometimes, and it’s still, still very common, and it’s just unbelievable.

Dr. Oster: I mean, I do wonder how much of this is sort of, like, patient push thing, where the patients, like, they just really want you to do stuff, and it’s very hard to hear, “Look, there’s nothing that we can do,” and this is something people have heard of. Seems like something that…like, it seems like it should be a good idea, you know, and then it’s just rather than… It’s very tempting to just say, you know, “You’re right. Let’s do that rather than, you know, fight with the patient about this.”

Dr. Fox: Yeah. I mean, a lot of times I’ll tell people, “No, I’m fine,” and then they’ll come back and say, “No, I was lying in bed all week.” Listen, if you want to, as long as you move around periodically, it’s okay, but sometimes it’s patient-driven. But there are doctors who either truly believe in it still, or even if they don’t believe in it, they just think that from a practical perspective it’s easier either for the patient or for them to just go along with the party line on this.

Dr. Oster: Yeah. But it is not the party line anymore, right? I mean, ACOG has been pretty…

Dr. Fox: No, no, no, not that party.

Dr. Oster: …has sort of moved on this.

Dr. Fox: Yeah. Different party.

Dr. Oster: Yeah, a different party line.

Dr. Fox: It’s definitely a party line in the Google. I have found it in the Google.

Dr. Oster: Right. You found it in the Google.

Dr. Fox: Google is sometimes very… Oh, my God. I had someone who asked me the other week, she said…I mean, she called me and she said, you know, “Am I in labor?” And I said, “Well, you know, no, you don’t have any contractions, and you don’t feel anything, and your cervix was three centimeters yesterday and is three centimeters today.” This is all from the office, and she goes, you know, “But Google said I was in labor.” I said, “Well, I’m going to take issue with Google on this one. I disagree. Maybe Google wants to deliver you.” So, it was just… I mean, listen, it happens. I don’t care. Like, people can look in Google and I don’t get mad by it. It was just so funny. Oh, my God, “Google said I’m in labor.”

Dr. Oster: That’s funny. “Google said,” they said.

Dr. Fox: Yeah. Well, all right.

Dr. Oster: It could be.

Dr. Fox: And then you said that labor and delivery is a lot easier because the evidence is good. So, I assume you meant things like epidurals and, I don’t know, induction or what… What were the issues that you found to be a little more straightforward?

Dr. Oster: So, I think, yeah, like, the epidural evidence is relatively easier to understand because there is some randomized evidence and because we kind of understand things like what would be… There’s a lot of sense in which, like, some of the risks are kind of biologically determined, right? It’s sort of, if you ask a question like, “Well, what is the risk of…? Like, what is the benefit?” Okay. So, we know what the benefit is, like that’s totally obvious. You don’t really need a randomized trial to know that it’s good pain relief. Then we have these other pieces of like, well, you know, would you get a fever? Do you get a fever? Do you shake? Like, there’s a lot of these things where kind of we have some biological sense of why you would have those side effects. And then just these are, you know, relatively straightforward things to run RCTs on, you know. Sometimes epidural is a little tricky because you can’t really force people into different choices but you can encourage them into different choices, and those kind of make hard [inaudible 00:42:59] science work well. And so, I think there were a lot of things in birth like that that just…it was just a bit easier to see because it was easier to read the data.

Dr. Fox: Right. What are your thoughts on birth plans?

Dr. Oster: So, I’m a bit of two minds on the birth plan. So, I had a birth plan. It’s in the book. It has some bullet points. I do think it is valuable for people to kind of think through what they want, and there were some pieces of, like, do you want to have an epidural? Do you want to have…? You know, do you want to be in a birthing…? You know, is there a birthing center? You know, it just helps the way… It’s a structural way to think through some options and decisions. I think where it becomes a problem or, you know, less helpful is when people get really wedded to some very specific idea about how things are going to go without recognizing the reality of birth is unpredictable and things happen that you weren’t expecting. That’s when this can kind of maybe cause more conflict than it eliminates.

Dr. Fox: Right. I mean, do you get a lot of people asking you, like, “What should I put in my birth plan? Can I copy yours?” Like, things like that.

Dr. Oster: Yeah. A lot of people are just like, “I copied your birth plan. It seemed fine.” All right, you know.

Dr. Fox: I think my wife had a birth plan, which was, “I want an epidural as soon as possible, and after that, I just want my husband just to shut up.” And that’s it, and I think it worked, you know.

Dr. Oster: Yes, you see? You know, that feels like…I feel like I would have had a hard time with my husband delivering on that, but that’s…

Dr. Fox: Yeah. It’s interesting, birth plans, a lot of doctors get very offended by them. They’re like, “Oh, do you have a plan for your appendectomy?” And, you know, they get very upset that someone have a birth plan, and, you know, I get it. It is like you wouldn’t walk into the dentist with a list of instruction of how to do things.

Dr. Oster: Right, demands.

Dr. Fox: And so, okay. Like, there’s something behind that, but I think that the idea is, in labor, there are a lot of things that are…you know, choices and preferences, and any good OB or midwife is going to be discussing these with women, like, “Do you want an epidural?” Like it’s very unusual than an OB would tell someone, “You must have an epidural or you can’t have an epidural.” I mean, it’s very, very unusual thing to say, and so it’s the choice of her as the woman. So, does it have to be written down, “I want an epidural. I don’t want an epidural”? So, I would say no, like, as long as you have that provider who you talk to and who will listen and you guys have a conversation, it doesn’t have to be written down. Might there be things that are valuable to write down? Because you may forget about them because you’re in labor, you know, things about, do you want the baby put on your chest right away? Do you want…? You know, like things like that as a reminder, and I think that that makes a lot of sense, but I agree, sometimes people get very detailed, like, “I need the lighting at a certain level and I need this music playing. Yeah, and you can be there, but you have to keep your left hand behind your back and you…” Like, it’s all these strange things, and I sometimes will tell them like, you know, “This is…you know, we can try, but it doesn’t always work out that way,” or you don’t want to put your doctor midwife in a position that he or she is uncomfortable with and not used to doing. Like, if I want…you know, it’s like saying to my plumber, “I want you to come fix my washer, but I don’t want you to use a wrench,” and like, “Well, but that’s what I use.” Like, “No, it could be done without one,” and then they’ll do it wrong. And so, I think that it’s really about communication, and if the best way to communicate is to put something in writing and discuss it, great. If the best way to communicate is just to have a conversation, that’s also great. I think these are things that should be discussed between the woman and her provider, but whether it needs to be written down or not, you know, whatever. If it’s something she needs, great, but it’s not something that has to be written down, and we don’t ask people to put a birth plan. We’ll go over them if they have it, but otherwise, we talk about women with these…about these decisions all the time, every labor.

Dr. Oster: Yeah. And I think the other thing too, you know, that sort of often when you get to the…by the time people get a second one, you realize, like, just stuff that’s going to happen that you didn’t really…that is hard to plan. I had this whole plan with my second that was like, “We’re going to have the…that was near the tub,” but when we got to the hospital, I was like, “How many in the tub?” It’s like the room with the tub. We made sure that we registered for the room with the tub, whatever, and then, you know, the baby is born 13 minutes after arrival at the hospital. So, I got in the tub and then I was like, “It’s coming out,” and they were like, “You can’t have the baby in the tub. Like, “You got to get out.”

Dr. Fox: We couldn’t even fill the tub yet, it’s dry.

Dr. Oster: [inaudible]. Right. That was like [inaudible], and then I was like, “Hey, the baby’s head there.” Like, “Get out of the tub.” So, all in all, it was that… I didn’t experience the tub like I had hoped.

Dr. Fox: What do you tell women? I’m sure a lot of people, and they do, or they have been probably with corona, what have you been telling people about home birth?

Dr. Oster: There are some risks. Probably the most significant risk is that there’s a reasonably high transfer rate. And so, you know, if you are planning a home birth, you have to accept that there’s some, you know, good chance, and depending on where you are and who your provider is, and if you’ve had a baby before, you know, that that number is sort of variable, but there’s not a nontrivial chance that you’ll end up in a hospital anyway. And that’s just something that people need to be prepared for, and that, you know, the evidence on does it increase infant mortality or other complications, you know, that evidence is mixed. Some evidence is sort of scary. Some evidence is more reassuring. And so, I find this to be a difficult thing to kind of give people advice on because I think my baseline assumption is it has to be slightly more risky, but, of course, it’ll also deliver some benefits. For some people, they really want to be in their house and they want that particular experience. I guess the main advice I would have, the main concrete advice is that, you know, you want a very highly-trained provider, a certified nurse, midwife, not somebody without significant training if you’re going to go that route.

Dr. Fox: Yeah. And I don’t know how many of your listeners, you know, in terms of where they’re asking from, but a lot of it also depends on sort of the region and what the system is. I mean, if you live in the U.K., home birth is pretty common and pretty safe, and the data from there shows it’s very safe because, not only do they have good people who are doing the deliveries at home, you know, in terms of the provider, they have a very tight system for what to do if things go wrong, and a transfer has to be made. How is it going to be done? Where is it going to be done? When is it going to be done? Meaning…because that’s fine. If you can get it all done very quickly, the likelihood of some disaster happening is very, very, very, very low. But if you’re just sort of winging it and say, “Hey, I’ll just call 911 and see what happens,” you know, you don’t know when they’re going to show up. You have no idea if the people who come in the ambulance will know much about pregnancy, where are they going to take you? They’re not going to know who you are. They’re going to have to do all this paperwork to get you registered. The people there are going to be a little upset that there’s a stranger showing up with a midwife, and that’s when bad things happen. And so, you know, where I live, there isn’t currently a great system for this. Maybe one day there will be. There are regions where it might be better. So, I think that’s another important thing, you know, how often is this done? What’s the plan if something goes wrong?

What hospital am I going to? How would I get there? And if the person living in your home says, “I don’t know,” I would shy away from that. If they’re like, “Oh, no, this is how we do it. Here’s the protocol. It’s written. This is what we do. There’s a hospital I work with,” then there may be some risks, but it’s much, much less, I would think.

Dr. Oster: The other thing I would often tell people is, you know, try to figure out, is there an alternative that deliver some of the benefits of what you…? You know, so like this great option that I was going to have, this great tub situation that I didn’t get to have with my second birth, like there’s the hospital on an island that everyone gives birth at has these alternative birthing centers, like rooms within the hospital where there’s a giant bed, there’s a tub. Like, you can’t have any pain relief, but it’s much closer to a home-like environment.

Dr. Fox: Listen, this has been a fantastic review of the dos and don’ts in pregnancy. You know, your book goes into all of these in much detail and more, obviously, there’s more topics and more details, and I have always recommended it. I think it’s great for women who are pregnant, thinking of becoming pregnant, even just someone who had a baby and wants to go back and rethink it and sort of, “Oh, this is interesting. I thought this, I thought this,” and it’s just…because it’s a quick read because it’s not written by one of like me, like boring, and stale, and medical. It’s written by a real human who writes, and so it’s much more readable in that sense. And I’m curious for our listeners, like, you know, what’s the tease for the next edition in January? Like, what’s coming in there that we didn’t have? Or what could we look forward to?

Dr. Oster: Two big things I added were pot and skincare.

Dr. Fox: That’s great. Definitely, we’re going to talk also another time about the other book you wrote at least on early parenting, which is “Cribsheet,” and just again for a teaser for our listeners, tell us a little bit about that book.

Dr. Oster: So, “Cribsheet,” I mean, it’s more or less is equal. So, the idea is to kind of take the same…you know, use data to make decisions into the years of early parenting. The kind of difference there is that there are a lot of topics where really the data is…where there isn’t really a right thing to do. And so, I think that that’s also true in pregnancy, but in some sense, it’s even more true, you know. There’s, like, some small risks, there’s some small benefits. A lot of that book is really about helping people kind of think about, you know, what’s going to work for you in your parenting, and how can you be confident in the choices that you’re making around things like, you know, circumcision or breastfeeding?

Dr. Fox: Oh, breastfeeding. That won’t be controversial at all.

Dr. Oster: Yes.

Dr. Fox: Yeah, no. 

Dr. Oster: No, no, exactly.

Dr. Fox: No one cares about that at all.

Dr. Oster: No one is interested in that.

Dr. Fox: No one is interested. And do you have…? Now that your kids are aging, do you have a thought about writing a book about adolescents, or teenager, or what to do when…

Dr. Oster: They are not that old yet.

Dr. Fox: …your daughter starts driving?

Dr. Oster: Yes, exactly.

Dr. Fox: How to be terrified.

Dr. Oster: Yeah. I feel like older kids are… It’s a little bit of a different ball game, so I’ve thought about that, but I think the question is exactly how to write something that would be useful for people when our kids are old, so when you…so much of parenting, and the slightly older age is really about, you know, parenting to your specific kid, which is a little less amenable to data. So, we’ll see. We’ll see.

Dr. Fox: Excellent. Emily, thank you so much for coming out. I always love talking to… It’s amazing.

Dr. Oster: Me too. It is great. Super fun.

Dr. Fox: Yeah. We’re going to do this again. The books that we were talking about today, one is “Expecting Better,” which has a new edition coming out in January. “Cribsheet.” You also have a website, which is, I think, emilyoster.net, I believe.

Dr. Oster: Yes. Exactly.

Dr. Fox: Yeah. And you can sign up for your newsletter, which I read every time it comes out, although it’s been a lot of corona. I’m still reading it.

Dr. Oster: A lot of corona. A lot of corona. Thank you for still reading.

Dr. Fox: Absolutely. All right. And so, well, have a wonderful day. Good luck.

Dr. Oster: All right. You too.

Dr. Fox: Hope this school year goes okay.

Dr. Oster: Yeah, great

Dr. Fox: Thanks, Emily. Bye-bye. 

Dr. Oster: Bye.

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@helpfulwoman.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.