“The Unexpected” – Emily Oster and Dr. Fox talk about their new book!

Emily: This is ParentData. I’m Emily Oster. Many years ago, I got an out-of-the-blue email from a doctor in New York. And he said, “Hey, I’m an OB, a maternal-fetal medicine specialist, actually, and one of my patients gave me your book. And I really think we would like each other. I think we agree on a lot of things.” And he attached a paper he had been writing that agreed with a lot of what I said in “Expecting Better.” And he said, “Next time you’re in New York, let’s have lunch.” And so a few months later, I found myself sitting at lunch, eating pita and hummus, across the table from Dr. Nate Fox. And indeed, we did see eye to eye on many things. And beyond that, we really liked each other.

Nate and I have stayed in touch since then. We wrote a paper together in a journal. And a couple of years ago when I thought about writing a fourth book about complications after pregnancy, I knew who I would call, and I called Nate. And I remember walking around outside, on the phone, pitching him this idea, “Hey, let’s write a book together about pregnancy complications. I don’t know exactly what it’ll look like. I don’t know exactly how it should be structured. I don’t know exactly what should be in it. But I know that you’re the person I should write it with. And Nate is always game. Without asking any more questions, he said yes.

And now, on April 30th, 2024, that book is out. The book is called “The Unexpected: Navigating Pregnancy During and After Complications.” And I invited Nate on the podcast, this is actually his second time on the ParentData podcast, to talk about our book, to talk about why we like to work together, and to answer some of the questions that people have asked us about navigating complicated pregnancy.

In this conversation, Nate and I will talk about some of the complications in the book. We’ll answer some questions. But we’re also gonna talk about some bigger-picture issues. How do you have good conversations with your doctor? How do you talk about especially these hard things when you’re both bringing different kinds of expertise to the table? We’re also gonna talk about risk, and how we communicate about risk, and why it’s hard to help people understand what a number like one third or 1% means.

Nate and I have different takes on exactly how to do this, but just like working on the book together, I feel like we got to a good place. Nate’s one of my favorite people to talk to. I call him all the time, and I’m delighted he came on this podcast, but even more delighted to have him as a partner in this book. So I hope you enjoy this conversation. After the break, Dr. Nathan Fox.

Nate Fox, welcome back to the podcast. Last time you were here, we talked about the ARRIVE trial, and we are now talking about our new book. You are my co-author and my friend. You’re the first co-author I’ve ever had on this podcast because I don’t write books with other people except for you. So, welcome.

Dr. Fox: I’m delighted to be here. You’re the first co-author I’ve ever been on a podcast with, so that’s a coincidence. Yeah. Since I don’t write any books nor go on many podcasts. So two for two.

Emily: Two for two. All right. So we’re gonna talk about our new book, “The Unexpected,” we’re gonna talk about some complicated pregnancy situations. We’re gonna get into all of it. But before we do that, could you introduce yourself, tell us who you are?

Dr. Fox: I am Nate Fox. I am a OB/GYN and maternal-fetal medicine specialist. I practice in New York City. I live in New Jersey. I have a wife, four children, and two dogs. And you are my hero. And I actually wanted to throw something at you, Professor.

Emily: Your payment is in the mail for that. Thank you, Nate.

Dr. Fox: Yeah, Professor, I wanna throw something at you. How did that taste going up, having to share a book with someone? You’re kind of a control kind of person, with your writing. And not in a bad way. I mean in a good way. You’re amazing, but you’ve never had to do this before, to sort of work with someone, so I’m curious how that worked for you.

Emily: Okay, so listen. To back up, Nate and I have a new book together. It’s called “The Unexpected: Navigating Pregnancy During and After Complications.” And it’s about navigating pregnancy complications ranging from miscarriage, to hyperemesis, to preterm birth. And the origin of this book is…so I wanted to write this book because people ask me about these things quite a lot, and I did not think that I could write it by myself because there’s a lot of complicated medical stuff in here.

And, actually, it turns out, I think, what you brought to the table is very different than what I thought you would bring to the table, which I can say more about. But you are right. I am not a group project kind of girl, you know? I’m more of a, like, tell everyone a job that’s not important, and then they do it, and then you do the whole thing and put the small numbers of things that they did. You know, like in…did you work on group projects in middle school? That was, like, my MO.

Dr. Fox: Yeah. I’ve been in that predicament. I have improved over my lifetime in group projects because medicine’s a lot of group projects, like, in a good way. But when I was in middle school, it was the same way. I was like, “Can you just all get outta my way and let me do my thing, and we’ll do fine.”

Emily: So that’s my MO, and I feel that I’ve improved over time, but I’m not sure that other people would necessarily say that. But you were the first person I thought of to write this book with because we’ve written together before, we’ve written a paper together. And I think you’re great. And actually, you turned out to be, like, far easier to work with than I thought you would be. And the main thing is that you’re very fast. You always do the things. You’re not, like, a malingerer, Nate.

Dr. Fox: I’m not a doctor, is what you’re saying. No, listen, I agree. I think that we had a very good working rapport because a lot of things about us are similar. We both answer our emails too quickly.

Emily: Exactly.

Dr. Fox: Like, before is [crosstalk 00:06:55]…

Emily: We’re, like, in our email. We’re, like, living in our computers. Yes.

Dr. Fox: Yeah. So we answer emails quickly, and we do things well before the deadline, and we’re both like that. But it is interesting. I will say, just from my perspective, I loved writing the book with you. First of all, you’re a professional. You’re really good at this. I’m not blowing smoke up your butt. Everyone knows you’re awesome at this. And so it’s a little intimidating to work with someone who’s so good at this because I’m…I’m not down on myself. I’m a lovely person. I think I’m a bright guy. I’m a good doctor. But I’m not a writer. Like, it’s not what I do.

And so it’s a little intimidating to go into a process with someone and I’m like, “Oh, my God, I’m gonna be terrible. I’m gonna suck. I’m gonna, like, hold her back,” and this or that. But whether I did or didn’t, you were very gracious. And you were always very encouraging and did not make me feel that way, either because I didn’t deserve to feel that way or because you were kind enough not to make me feel the way. I don’t really care. Either one is fine. But it was really a delight.

And I could say that I’ve actually always toyed around with writing a book. Years ago, I said, “I wanna write a book.” But, you know, I mean, well, I’m not gonna write a book. Right? So I thought I would, and one of the things I really, really wanted to talk about in a book was not so much, like, nuts and bolts medical-type books. I’ve written medical chapters before for textbooks. But not that, that’s not writing. That’s horrifying. But writing to people who see doctors to try to give them an insight as to, like, how do you know what to do, like, what to ask? How do you know if your doctor’s any good? Right? How do you know if, like, this is productive or not?

Because, I mean, you know if your doctor’s nice, and you know if their office is clean, and you know if they run on time, and you know if their billing department’s annoying. Like, you know those things. But you have no idea if your doctor’s any good. You could see a diploma on the wall, but the correlation between that and a good doctor is very minimal. Right? And it’s hard, legitimately. Listen, I’m also a patient. And my wife’s a patient, my kids are patients. I don’t know if our doctors are good. It’s very, very hard. And so that was something I always wanted to do. And when this project came along, it actually worked out perfectly because it’s what we both wanted to do from different angles. And so I think one of the reasons it was really fun, in that sense, for me.

Emily: So let me give people a little bit of a sense of what the book is, what the book is like.

Dr. Fox: Yeah. The book is awesome.

Emily: Well, first of all, it’s great. I mean, so this is a book about navigating pregnancy after complications. And I think we really have written it with the idea that, you know, people have had a complication in one pregnancy and are thinking about how to navigate another one. And we say this in the book, but about 50% of pregnancies either ended or include one of the complications that we talk about here. So it’s a pretty large share of pregnancies. And what the book does is there’s some sort of general material at the top to try to help people think about what kinds of information they should have out of their medical records and how to kind of navigate their way into that.

And then there are a series of chapters, in which, first, sort of, there’s Emily talking about the answers to many of the questions I get, which are like, will this happen again? What’s the risk of recurrence? What kind of treatments are there? Can you help me just understand what this complication is? And then there’s your part of the chapter, which is about, how do I have a conversation about this with my doctor?

In the case of many of these complications, probably all of them, there’s not, like, one answer. It’s not like, if this happened, like, for sure, this is what we’ll do next time, and everything will be fine, and, you know, thanks for the data. A lot of it is about the nuances of a particular case and just the details of how to move through it. And so the thing that I think we get out of your parts of the book are just how to navigate those conversations.

And I will say, I had a conversation the other day with someone who sort of works in birth trauma and who was very influential for me in thinking about writing this book. She said, “I started reading this book, and I thought, you know, ‘This is gonna be kind of like “Expecting Better” but for complications, and this is gonna be a great resource. And I’m glad that this is gonna be available.’” And then she said, “But, actually, the book is so much better than that because Nate’s parts are so great. And, like, your parts are fine. I expected them to be like they are. But this additional piece is the most important thing in the book.” So, for me, it’s part of what I didn’t expect you to bring to the table. And I do think it’s probably among the strongest pieces of the book.

Dr. Fox: Oh, well, it’s very touching. You know, I think that in terms of the book itself, it seems like it’s written for people who had a pregnancy that didn’t go well or had a bump in the road and they’re trying to figure out what to do next time around. That’s sort of like, I would say, the surface level. And that’s probably the bulk of people who are going to get this book, it’s for that reason. But I would argue that, in fact, it’s much more than that.

And number one, if someone is fortunate enough to never have had a pregnancy with a complication, which is actually unusual, but let’s say that’s the case, everyone knows someone who had a pregnancy with a complication. Everybody knows someone. It may be their sister, their friend, whatever. And I think that this book is also written in a way to help people understand what their circle of people have gone through and to just give an appreciation for that and what their thinking and what their fears are and what their concerns are.

And I think also, just in general, since the complications are so ubiquitous, we’re talking about…this is not crazy things that no one’s ever heard of. We’re talking about miscarriage, preterm birth, like, bleeding. I mean, things that so many people have in pregnancy and people talk about, this really gives people an understanding of them or of pregnancy at a much higher level. So even someone who’s never been pregnant or is never gonna be pregnant, it’s sort of interesting in that sense to understand it.

And I think on the deepest level, what I was trying to bring to the table is also, even for someone who’s literally never gonna be pregnant, talking about a single guy, whatever it is, I try to get into that concept of what’s happening when you’re with your doctor, and why it’s so complicated, and why it’s so rich. Like, it’s a relationship. It’s not like ChatGPT, where you plug something in and you get back a response. It involves personalities, it involves emotions, it involves nuance.

And although this is related to pregnancy, obviously, and that’s sort of the framework we use, the principles are very broad. And that’s sort of what I was thinking, it’s not just, you know, nuts and bolts, it’s sort of high-level what’s happening in these meetings. And this would be, I would think, relevant for anybody about to see a doctor for a question. How do I think about it? How do I talk about it? What am I looking for? How do I know if they’re answering my questions? Because that’s, like, the golden question out there.

Emily: I mean, I think there’s a sense in which patients bring one kind of expertise, and doctors bring another kind of expertise. And some of these conversations are about kind of how do we bring those together. And it’s hard to bring those together if patients don’t know about what’s going on. And it’s hard to bring those together on the other side if doctors are kind of not prepared to have nuanced conversations that involve patient preferences.

And so I think the book is a little bit about scaffolding those conversations, as you say, like, in any setting, although, you know, the particular examples are in this complicated pregnancy space. I don’t know, I feel like it’s kind of interesting for the two of us to write that because that is effectively what we try to do working together, is, like, recognize that, like, you have a set of expertise that I don’t have, and I have a set of expertise that you don’t have, and, like, we’re trying to bring them together to kind of work as a team.

Dr. Fox: Yeah. I mean it’s part of, you know, this very loaded and confusing term that people use, which is shared decision-making. And in medicine, that’s a big thing now. I hear it, you know, with the residents and the med students, shared decision-making. And I always say to them, like, “What do you mean by that?” Like, it sounds great. We’re sharing. We’re making decisions.

Emily: We’re sharing. Sharing is caring.

Dr. Fox: Right. It sounds delightful. But how does that work in practice? Because in practice, you know, the patient is the person who knows herself the best, her personality, her wants, her wishes, her fears, her experiences. I don’t know anything about that. I may have an insight just by talking to her and knowing her, but she knows herself way better than I know her. And I know the medical side. I don’t expect her to know the medicine. Like, she may have been a great Googler, but, you know, I went to medical school, I did the training, I do this for a living.

And so the best part of shared decision-making is she brings to the table her expertise about herself, and I bring to the table my expertise about the medical side, and we try to use both of those expertise together to come up for the right answer for what to do for her, to individualize it. That’s how it should be. But what ends up happening is people say shared decision-making, and then what ends up happening is the doctor says, “Well, you can do A, B, or C,” and it’s your choice. And some people are like, “Great, I get to choose.” And other people are like, “What the hell? I don’t know. Like, how am I supposed to know?” Like, if my plumber said to me…

Emily: “Did you go to business school?” Like, “Did you go to medical school?”

Dr. Fox: I mean, literally, if my plumber said to me, “Well, you know, we could use copper pipes, or we can use plastic pipes. What do you want?” I’d be like, “What [inaudible 00:16:40]? Do look like a plumber? Like, I have no idea. Like, you tell me what’s better.” Now, if the plumber said to me, “From my expertise, the copper pipes…” And this may be false, but, “The copper pipes are more expensive, but they’re gonna last 10 years, whereas the plastic pipes are less expensive, and they’re gonna last 3 years,” and I know how much money I have, whether I’m leaving the house in three years, how much it bothers me to have a plumber come back, and so that’s shared decisionmaking. But if you just said, “Here are your choices, let me know what you want,” that’s not shared decision-making. And that’s what ends up happening a lot. And it’s very frustrating, both for doctors and for patients, when it’s not done in the ideal setting or the ideal way, I would say.

Emily: Yeah, I think one of the nuances of those conversations is that whose expertise should get more weight depends quite a lot on what is the decision that you are making. So, you know, if I am in the… I had this experience, you know, eight months ago, where I was in the ER. Like, I had a bike accident. Like, an accident with a bike. I was running, they were biking. And I ended up in the hospital with, like…

Dr. Fox: You got hit by a bike.

Emily: That makes it sound like it was the bike’s fault, whereas it was really more of a joint fault. But anyway, I ended up in the hospital with a laceration in my head. And in that moment, like, my expertise in my own feelings about, like, my head and so on is really not relevant. Like, the question is, like, somebody needs to figure out if you have a skull fracture or not. And that’s the doctor’s expertise, and you kind of have to defer.

And then there are settings in which it’s almost entirely about patient preferences. One of the ones we’ve talked about various places is, like, what kind of genetic testing people want. So if you’re pregnant and you want some genetic testing, that’s really a lot about what would you do with that information? What are your feelings about the results out of that? And the doctor can provide information about what you learn from the test, but ultimately, the patient preferences really win. And then there are many things in the middle, where there’s a combination of kind of expertise about your medical situation and what’s possible with, you know, what does patient preference look like?

Dr. Fox: Yeah, 100%. And I think that, again, it always depends on the context. So when I’m teaching the residents and they have a patient who’s, you know, coming in and she’s got some problem, and I always say to them, “What do you want to do?” Because they’ll present the patient, and the goal of it is not for them to present it to me to tell them what to do, it’s, like, teaching. So I say, “What would you like to do?” And frequently, what I get back is, “Well, we could do this, we could do this, or we could do this.” And I would say, “Okay. I’m aware of the choices. Tell me, what do you want to do?” And they get very uncomfortable.

Because what happens is, earlier medical training, you know, many, many years ago, it was very paternalistic. And doctors were basically trained, you’re the doctor, you’re the professional, you’re gonna tell your patient what to do, and he or she’s gonna listen to you or they are horrible people. And that’s sort of how it went in medicine. And there has been a pushback against that, I think in a good way. But now I think the pendulum has sort of gone the other way, where people are being trained in medicine, patient autonomy. He should make the choice, she should make the choice. You know, present them with options, and they’ll choose.

But neither is really correct. It depends on the circumstances. And so if the patient’s hemorrhaging, I’m not gonna say, you know, “Which medication would you like for me to help you stop hemorrhaging?” Like, then I’m an idiot, and, like, I’m a terrible doctor. But for things like genetic testing, if I tell her, “You’re gonna do A, B, and C,” that’s also really not good. And so you have to sort of know the situation. You gotta read the room, in a sense. Like, you have to read the room. What does he or she want? Do they want you to be a little bit more, “Tell me what to do,” versus, “Give me choices?” And what does the decision that we’re making call for?

Emily: So there’s a sort of class example of shared decision-making I wanna talk about here, which is sort of how should people think about a VBAC, about a vaginal birth after cesarean. And so this is a case in which someone has had at least one, but let’s say they’ve had one, cesarean section with their first birth, they’re thinking about sort of what to do birth-wise for the second birth. So there’s an option, which is to try for a vaginal birth, there’s another option to have a repeat C-section.

This is something we talk a lot about in the book. It’s usually a little bit different than some of the other complications in the book because a cesarean section is not sort of properly a pregnancy complication the way preterm birth or preeclampsia is. But it is something we wanted to include because many people wonder about this in a subsequent pregnancy when they’ve had a C-section the first time. So let’s do a little Dr. Nate. So I come in, I say, you know, I had a C-section in my first birth. I’m trying to decide about this next birth. What are you asking me?

Dr. Fox: So, I mean, essentially, this is the paradigm of the shared decision-making. Because there is something medical that I need to know and I need to weigh in on. So, for example, what kind of C-section did you have, meaning what kind of incision on the uterus? Ninety-nine percent of people who have a C-section have what we call a low transverse incision, which means it was low down on the uterus, meaning towards the bottom of uterus versus towards the top. And transverse means the incision goes side to side versus up and down.

If you had that type of incision, then in the next pregnancy, if you try to labor, your risk of a uterine rupture is, ballpark, 1%. It’s probably slightly less, but let’s just say 1% because it’s an easy number. Versus if you had the other type, it’s much higher. So I need to know that from a medical side to tell you whether it’s even on the table to try to deliver vaginally because whether it’s possibly safe or unsafe.

Next is what were the circumstances of your C-section? Why did you have the C-section? Was it because you had a 6-pound baby and pushed for 8 hours, and the baby didn’t come out? That’s a little bit, like, sort of…doesn’t sound as good for your future prospects, although it’s not definitive. Versus “I had a totally healthy pregnancy, but since it was twins and they were both breech, they said to do a C-section.” And no, that’s not so much related to the risk in the next pregnancy, but the likelihood of success in the next pregnancy, with success being defined as a vaginal delivery, although obviously success is healthy mother, healthy baby, but we’re talking specifically about this.

So, for me, based on her history, based on maybe reviewing her records, maybe an examination of her, maybe an ultrasound, whatever, some tests, what I bring to the table is, “All right, here’s the likelihood that if you tried, you would be successful.” Is it 50%, 70%, 90%, whatever it is. And what is the risk to you if you try it? Is it in that 1% range, or is it much higher? That’s what I bring to the table.

But what she brings to the table is, well, what does she want? And so I always ask her at the beginning of this, in addition to all those questions, I say, “What are you looking for? Like, what is it you’re trying to get here? Are you looking to try to have a vaginal delivery? Are you looking for a repeat C-section? Do you have no idea, and you wanna sort of learn about each of those? I need to see what she wants and what are her fears.

And I’ll have the same sort of clinical circumstances, let’s say, and one person says, “I really, really wanna try VBAC, and I’m willing to accept certain risk and certain likelihood of success,” and someone else is like, “I want no part of that. I want a repeat C-section.” And those are both good decisions, in my opinion. So you have the same facts on the table from my end, but they lead to different decisions because the facts on the table from her end are different, what she wants. And vice versa. I could have two women who want the same thing, but they’re gonna have different numbers on my end. And one of them, I’ll say, “You have a 50% chance of success,” and the other one, “You have a 90-plus chance of success.” And so then they may decide differently.

And so that’s really how shared decision-making is supposed to work. And unfortunately, it doesn’t, either because the doctor’s not doing their job by getting the right information or inquiring what does she want and getting her opinion or because potentially it’s trying to be done, but let’s say the hospital doesn’t have an option for VBAC, so it’s irrelevant, almost, in a sense. And there’s a lot of stuff that goes into that, but that’s what we’re trying to get at in this book, to help people create those kinds of conversations or find someone who can have that conversation with you so you can come to a good decision.

Emily: So how long do you think that conversation should take?

Dr. Fox: Literally, it could take…it could be as short as 5 to 10 minutes. It does not have to be very long. If someone doesn’t want to labor and just wants a repeat C-section, it could be two minutes, just because I have to make sure she understands that there’s risk to a C-section, that it’s not, you know, unicorns and rainbows. She should know, she had a prior C-section. But just, you know, for example, I’ll say, “How many kids do you wanna have?” If she says nine, then the second delivery, whether it’s a vaginal or C-section, is gonna have a lot more implication for her future health. Because if she has her second, she’ll end up with nine C-sections, whereas if she delivers vaginally, it might be one C-section, followed by eight vaginal births.

But short of that, it could be very, very short. Sometimes it’s very, very long. Sometimes we’re working through what does she want? What are the risks? What does this mean? What does that mean? What would happen if…? What would happen if…? And that’s fine, and it’s rarely not that long if everyone comes to the table with sort of a mutual understanding of what we’re trying to do here.

Emily: And I think for me, that is a lot of what I’m trying to deliver with this book. Because it feels often as a patient that one’s time is quite limited. You know, I think there are circumstances in which you can get much more time with your doctor, but a lot of us, we’re looking at, you know, 15 minutes at a visit, and that’s not very much time. And if you come in better informed, with a sense of your questions and a sense of what you are trying to get out of the visit or what the choices even might be, it can make those conversations more productive. And I think this book is really about kind of, okay, let’s get enough background knowledge, you can kind of come into that conversation in the right way.

Dr. Fox: Yeah. You and I are both lovers of efficiency.

Emily: Yes.

Dr. Fox: And so it definitely makes it more efficient. One of the nice things about VBAC is it’s rarely something that has to be made on the spot. Meaning you can have that conversation early and see how it evolves. And it’s also part of the ongoing data. Someone might normally be someone who wants to have a VBAC, but then they find out later in pregnancy, the estimated weight’s 10 pounds, and they may feel differently about that. Or vice versa. They may be someone who said, “You know what, I really don’t want to take that risk or that, and I really prefer a C-section,” but then a week before her scheduled C-section, she comes in labor, and she’s 8 centimeters dilated, and the head’s, like, low on the pelvis, I’m like, “Wait. Like, now the data has changed. We can maybe revisit this.”

There are other conversations that are a little more time specific, like genetic testing. And I’ll tell you that when I…I lecture a lot about genetic testing, and it’s, like, one of the things I talk about. And so many people, they say, and it’s true, “This is so hard.” Like, this is such complex stuff. No one understands this.” How could you possibly have a conversation with your doctor…or a doctor have a conversation with a patient and put ’em at a level that they can understand this?

And the answer is they can’t. That’s true. You know, you need an hour, let’s say. But if someone has a basic understanding of what we’re talking about and the person who’s doing the counseling, the doctor or the genetic counselor, really is focusing on what we’re trying to answer, it doesn’t take that long. Because you can sort of hone in on the question. You know, like, “If your risk were 1%, does that number seem scary to you or reassuring to you?” Like, it’s a very simple question that people can answer.

And I’ll tell ’em, like, you know, if all your testing is normal, your non-invasive testing, your ultrasound this, your risk of a baby with Down syndrome is very, very low, 1 in 10,000, but your risk of any genetic condition is 1%. Does that number reassure you or scare you? And if it reassures you, get up and leave. Like, you’re done. Have a good day. Whereas if that terrifies you, you should be thinking about a CVS or an amnio. And that’s a very straightforward question that most people can answer. Not everybody. Some people are like, “I don’t know how I feel about 1%.” Fine. Think about it, get back to me. But it requires a lot to get to that question. And so, again, it’s on the doctor, it’s on the patient, it’s on everybody to try to make these more productive. And I hope that this book is very helpful with that.

Emily: No, but I think you’re right, that sort of we have this idea that, like, to do that, you would need to have somebody understand, like, all of the incredible, you know, details about how exactly we’re running these tests and what exactly all of these genetic things mean and so on. But that’s not really…if you can get to the question that is relevant for decision-making, it may actually be that that is much simpler than, like, an, you know, college-level course in genetics.

Dr. Fox: Yeah. Like for VBAC, I often tell people, you know, there’s three ways this can go. You can try for a VBAC and have a successful VBAC. That’s sort of the best option. You can try for a VBAC and not have a successful VBAC, which might be the worst option unless someone feels like, “I’d rather try and fail than not try.” And then there’s the middle option, which is sort of like, “I don’t do either. I don’t try, and I just have a C-section.” And I always say to them, when you go for a VBAC, you’re gonna get the best or the worst, you’re not gonna go to the middle.

So are you the type of person who would roll the dice a little bit, so to speak, to try to get the best option, knowing it may backfire? Again, not backfire like die, but, like, you know, whatever in terms of maybe overall outcome. Or are you the type person who really, “I’d rather just do the middle of the road?” And people can wrap their heads around that. They know who they are. And so we try to help people make these decisions by framing the questions in a way that if you’re this type of person, you’re likely to go this direction, whereas if you’re this type of person, you’re likely to go this type of direction. And that, I found to be helpful over the years to try to let people…give them that context to make complicated decisions.

Emily: More ParentData after the break. All right, so let’s test this out for a minute. We’re gonna see where the rubber meets the road. I’ve invited Tamar, my producer, in to ask Nate and I some questions.

Tamar: Hello?

Dr. Fox: Hi, Tamar. All right, so we were not given the questions in advance. This is not like “Quiz Show.”

Emily: Great. Let’s do it.

Tamar: Okay. So, I have tested positive as a cystic fibrosis carrier. My husband still needs to be tested. We have the appointment in another week. How much should I be freaking out?

Dr. Fox: Minimally, is the answer, how much you should be freaking out. Essentially, with carrier screening, which is what we’re talking about, we’re checking to see if the couple has usually autosomal recessive conditions, which are the kind that you can carry and not have a condition, and to see if they both have the same one. So when we do a full panel, it’s hundreds and hundreds of conditions, and you tested positive for cystic fibrosis, okay? You yourself have no cystic fibrosis, no medical issues, you would never know you had this in your entire life. It’s only relevant if the person with whom you are procreating also has a mutation for cystic fibrosis.

So the question is, what is the chance of that? I believe the population frequency depends on his ancestry, but let’s say it’s 1 in 50, 2%. So the chance that you’re a couple that both carry cystic fibrosis is 2%. And if he carries cystic fibrosis, then each of your kids has a 25% chance of having it, which you could either get pregnant and test and find out or do IVF and test the embryos and only put in embryos who don’t have cystic fibrosis. So all that’s available to you, but I’m glad you’re doing the testing, it’s good to know. But minimally, is what I would say in terms of how much to freak out.

And when you undergo advanced and comprehensive genetic screening, more than 50% of people will get back a positive “abnormal result,” meaning you have a mutation that’s very, very common. It’s not unexpected, it’s not a problem, it’s not a health issue. It’s not any issue whatsoever unless you happen to be procreating with someone who has the same mutation, which is unlikely.

Tamar: Okay, this one’s for Emily. Are kick counts just torture devices for type A personalities?

Emily: So data on kick counts is a little mixed. So the idea behind kick counting is that it is a method to prevent stillbirth, which is one of the complications we talk through in in the book. The idea is that you would count for some period of time every day, particularly towards the end of pregnancy. You would look for, say, some number of movements in an hour or count until you get to some number. There’s a few different methods for this. And it’s a structured way to detect abnormal changes in movement, which could indicate a problem with the baby.

Like, theoretically, it seems like this could help do that kind of detection. In practice, the evidence to support this as an important method for preventing stillbirth is quite weak. I think part of the issue is that stillbirth, while more common than many people think, is still very rare. And so it’s very difficult to run a large trial that would actually detect changes in stillbirth, just because the overall prevalence is low, and so any changes, you need a lot of data to detect them statistically.

So, I think this is one of the cases where it actually depends a little bit on how someone’s gonna kind of come to it emotionally. So for some people, this is very reassuring, and it’s like, “I’m gonna do this. I’m gonna put it on my calendar. I’m gonna do it every day.” That’ll sort of be a positive experience. And for some people, it’s super anxiety provoking. We do get more visits to doctors as a result of this because people want reassurance. So I’m not sure there’s a 100% answer to whether this is the right thing for everybody.

Dr. Fox: No, I mean, listen, I agree. I think the issue is, yes, if a baby is moving or appears to be moving less than expected, that usually means nothing, but it’s something we want to know about. And so we have people come in and check it out. Fine. Every now and again, we do see something that’s real, and we intervene, and we think, you know, it improved the outcome. The question is whether it’s valuable to tell everyone who’s pregnant, “Do some sort of formal test at home to make sure your baby’s moving okay.” Are you gonna “save any babies” compared to the many, many, many people you’re gonna freak out? And so that is the question that’s quite unclear.

So I don’t typically recommend kick counting as a routine, but I tell people if they feel their baby’s moving abnormally one day…because most people know their babies. Some babies are pretty active, some babies are less, some babies move at night, some babies move in the morning. You know, babies have personalities, just like adults do. And so if you think there’s a change and something’s unusual and you’re concerned, then I will say, all right, lie down, close your eyes, focus on the baby. Wait 30 minutes. If you feel three movements, it’s okay. And if you don’t, let us know.

But as a routine, I don’t…anyone who’s high risk enough for stillbirth, I have them come to the office once or twice a week for, like, formal testing, whether it’s a biophysical profile or a nonstress test, so we can really get, you know, something with data on it and something we really can see. Whereas if someone is at low risk for stillbirth, I generally just say just keep an eye on your baby, and if everything seems normal, you’re good to go.

Tamar: As a migraine sufferer during pregnancy, like, I always had my Tylenol at the ready. But I was Googling, and I noticed that it actually depends… Emily’s shaking her head at my Googling. That taking ibuprofen or an NSAID during pregnancy is actually…like, it’s different when in the pregnancy you take it. Is it the kind of thing that is just blanket never take ibuprofen during a pregnancy, or does it actually matter when?

Dr. Fox: It matters. So Tylenol and ibuprofen are different, just to be clear, because you first said Tylenol, and then you said ibuprofen. So Tylenol, you can also Google some bad things about Tylenol, but basically, the overwhelming evidence is that Tylenol is safe. And the studies that seem to scare people about Tylenol are very complicated. Because it could be the reason someone took Tylenol, which is usually fever, illness, this or that. So Tylenol is separate. Ibuprofen, which is like Motrin, which is like…

Emily: Advil.

Dr. Fox: …Advil, or another NSAID like naproxen, or Aleve, it’s not a concern, as far as I know, in terms of birth defects, like, early in pregnancy. Later in pregnancy and sort of the mid to late third trimester, there is a risk of it affecting one of the blood vessels in the baby’s heart. So we tell people not to take it in the third trimester. The reason we tell people not to take it in the first and second trimester is predominantly because we don’t want people to sort of get confused which one. Because people always confuse…like, you know, we just heard Tylenol, Motrin, Advil. And so we tell ’em not to take that sort of ever so they don’t end up taking it in the third trimester.

But if someone needed it at 18 weeks, they could take it, and we tell them, you know, this. So we sort of do give it to people for certain circumstances. But, yes, later in pregnancy, it becomes definitely don’t take it later in pregnancy. But exactly when, exactly how much, it’s a little bit complicated, which is why there’s more of a blanket statement not to take ibuprofen, because it will become dangerous. But there are a lot of nuances to that.

Tamar: Yeah. I will say, like, as a chronic pain sufferer, that made pregnancy really…like, it was the ultimate, like, “Is it me or my baby?” You know, it’s like how can I get through the day?

Dr. Fox: Each medication requires a conversation and, you know, a discussion. But there are options for people with pain, and there are options for people with migraine pain. And I think that sometimes people feel like they can’t take anything because, like you said, it’s me versus the baby, which is actually the exception. It’s very unusual that there’s a me-versus-the-baby conversation. It happens so rarely. It’s almost always what’s good for the mother is good for the baby, or there’s three options that are good for the mother, and we’ll pick the one that’s safest for the baby.

Tamar: Okay. Okay, last one. Do doctors suggest C-sections, you know, to make their tee times? Is that a really, like, outdated worry, that doctors kind of jump to suggest C-sections in order to make it faster for them?

Emily: Dah-dah-dah.

Dr. Fox: Well, that’s pretty loaded. So for the record, I do not golf. So I would never do it for tee time. Listen, are there doctors who make recommendations because it’s easier for them than the patient? I’m sure. I’m sure they exist. I mean, I don’t know how many doctors there are in the United States. A million? I don’t know what the number is. Many, many, many doctors. And I’m sure there are ones that make recommendations that are not in the best interest of their patients. I would say, in my experience of knowing doctors, talking to doctors, meeting doctors, or working with doctors, very rare. It doesn’t work like that, typically. And I would say that, especially in the field of obstetrics, the way things have evolved, you rarely have that solo practitioner who’s deciding between a tee time and a birth.

So, like, take my schedule, for example. If I’m covering the labor floor, I am on the labor floor from 7 a.m. to 7 p.m. Makes no difference to me whether someone has a vaginal birth or a C-section from my convenience. Like, whatever’s best for her is best for her. And similarly, I’m being relieved by someone at 7 p.m. who is fresh, and, you know, slept, and capable, and had dinner, and is someone I trust. And so whether someone has a C-section at 6 p.m. or we wait and they have it at 9 p.m., or they deliver vaginally overnight doesn’t matter to me. There’s no upside or downside to me. So I think nowadays that type of behavior, if it existed or to what degree it existed, must be much less because there aren’t the same time pressures on obstetricians that there may have used to be.

Emily: Can I make one…can I say one thing?

Dr. Fox: No. No. No, you cannot.

Emily: Absolutely not. Because you have a tee time to get to.

Dr. Fox: Yeah.

Emily: So I think one piece related to this is about inductions, which comes up a lot. And you and I have talked about this, that basically, labor induction can be very slow. And so [crosstalk 00:41:57]…

Dr. Fox: Right. But the doctor doesn’t have to be there.

Emily: It’s not the doctor, yes. But just for people, a kind of point related to, like, getting from an induction to a C-section, like, something I think is really important for people to understand is that labor induction itself can be extremely slow. And so if you are going to have an induced labor and you’re planning for a vaginal birth at the end of that, which would be typical, you and your doctor…they will be prepared because doctors know this, but you should be prepared that it will be very slow.

Dr. Fox: Yeah. I would say that the one thing that sadly does drive a lot of decisions regarding mode of delivery, C-section versus vaginal, is either the actual fear of getting sued, of litigation, or even if it’s not actual, it’s sort of built into the system. There are so many safeguards built into the system that end up increasing the risk of C-sections that we’re not even aware of, in a certain sense, and they’re built in there because of fear of lawsuits. Because it’s not just the doctor that’s afraid of getting sued, the nurses are afraid of getting sued, the hospital’s afraid of getting sued. The hospital’s insurance carrier is afraid of getting sued. And so, sadly, that is sort of cooked into the numbers sometimes.

And it’s unfortunate. It just is. But it’s a reality. And I’m not saying that from, like, a political reason about what to do about it, because there isn’t a great solution. But I think that definitely, doctors sometimes consciously or subconsciously worry about, well, the chance of something going wrong is very low, and medically, it’s probably okay to continue if she wants to, but if something were to go wrong, it’s not gonna look good on paper, and I’m gonna be in big trouble. And either that means I’ll get sued or the hospital’s gonna come down on me because they’re gonna get sued, so they’re gonna restrict my privileges.

And, again, I’m not saying that to complain. It’s a reality of the system. And it’s hard. I don’t know what the solution is, but that is probably a more prevalent factor than the doctors’ tee times, or show tickets, or dinner reservations, or, you know, whatever the doctors are supposedly doing in high society that the regular people aren’t. So, yeah, we’re probably going home to our second job, is what we’re doing, so…

Tamar: Okay. Well, thank you both. I will see myself out.

Emily: Thank you, Tamar. So I had a last topic I wanna talk about because I think it is something that we don’t agree on, and there are very few things like this.

Dr. Fox: Who? Me and you?

Emily: Yeah.

Dr. Fox: Oh, dear.

Emily: And it is about how much detail people want on risks. So one of the things I spend a lot of time on, like, in my work, in my book, and so on, is trying to be, like, super precise about, you know, is the risk of recurrence of this condition, you know, 16%, or 20%, or 25%? And in even writing this book, I spent a huge amount of time in that space of, like, let me try to, like, get as close as I can to some, you know, precise number and understand how much variation there is and so on.

And you came into this, I think, with an idea that there are kind of three categories of risk that you like to explain to people. There’s, like, probably this won’t happen again. You know, most of the time, this is kind of pretty idiosyncratic, so it’s probably not gonna happen again. It might happen again, but you don’t really know. Or you should assume it’s gonna happen again, and if it doesn’t, you’re lucky, I think is how you put it. So you were kind of like pooh-poohed my precision around risk.

Dr. Fox: No, never. Never.

Emily: And I think part of that is…I think part of it comes from the clinical, maybe the sort of expertise of talking to people and saying, like, people don’t really…like, fundamentally, the difference between 65% and 70% isn’t actually very meaningful when people make decisions.

Dr. Fox: So I don’t think we disagree. I think that it’s more so the practicality of it. Meaning I’m a data person. I love data. I think that there’s two issues with trying to get that precise. Number one, the research we have in almost all of these aspects is so limited that the difference between 16% and 21% is usually nothing. Because the brackets around them are wide enough that it really doesn’t…there is no actual difference between those numbers, which you understand better than I do, but sort of statistically. So that’s one issue.

The second is, I don’t think most people think like you think. So I think there are people, and I’ve certainly taken care of them, come across them, have some in my family or this, who they’re like, “No, I wanna know, is it closer to 16 or closer to 21? And fine, I’ll tell you. Like, God bless. You know, we’ll go to the decimal point. However many sig figs you want, we’ll go there. No problem. But most people don’t think like that. Most people, when they’re thinking about risk, they categorize in their brain, like, “High risk, low risk, medium risk. Where am I?” And so I sort of usually break it down, again, based on the risk, into something like less than 10, 10 to 50, or more than 50.

Again, it depends on…sometimes all of them are under 10, and it’s like, all right, less than 1, 1 to 5, 5 to 10. Like, it depends on the…but try to give them a sense so they can wrap their head around the statistics. Because most people, the average person is functioning at, you know, I don’t know, a middle school level when it comes to statistics. That’s not an insult. That’s, like, high-functioning people who are very bright and working in the world, that’s the level of statistics they’re usually working at. The exception are the people who are very, very into data and wanna know the exact decimals. And God bless them, but they’re the exception. They’re the outliers I would say.

And so, for me, if you get into very, very precise numbers with people, you lose them. In counseling. Now, with reading, it might be different because it’s a reference versus a conversation. They hear 17%, what does that mean to them? And also, the other thing is, people think about math differently. So I always have to say those numbers twice. I’ll say, “Your risk is 30%, your risk is about 3 out of 10, about 1 out of 3.” Like, you have to say it in so many different ways because people hear things differently. Some people don’t get percentages.

When I tell people 1 in 10,000, some people don’t get what that means. And, again, not that they don’t understand it, it’s just they’re hearing it and they may be more of a verbal learner, and you have to write something down or… It’s fascinating. The human brain is fascinating. And so we see all comers. And that’s sort of what I was getting at, not so much that it doesn’t matter, but it’s usually not practical.

Emily: Yeah. No, I think that’s fair. I mean, this question of how people understand probabilities, particularly small probabilities, is, like, an incredibly interesting one. Like, how do you help somebody understand 1 in 10,000, since, like, most of the time you won’t experience something? And how is 1 in 10,000 different from 1 in 100,000? You’re never gonna see either of those in your life, you know.

Dr. Fox: I tell people that. You know, when we talk about…I’ll go back to the genetic screening thing, where I’ll tell people their risk is 1%. And if they do an amnio or CVS, their risk of a miscarriage is, let’s say, 1 in 500, a little less than 1%. And I’ll tell them, “All right, you have two options here. You’re gonna do a procedure, you’re not gonna do a procedure.” And I said, “Think about it. You can close your eyes and flip a coin and make this decision. And whether the coin lands heads or tails, 99-plus percent of the time, you’re not gonna miscarry, and you’re gonna have a healthy baby.”

I said, “No matter what, if you do a CVS, 99-plus percent of the time, you’re not gonna miscarry. You’re gonna have a healthy baby. And if you don’t do a CVS, 99-plus percent of the time, you’re not gonna miscarry. You’re gonna have a healthy baby. How often in your life do you get to make a decision that’s important to you where 99-plus percent of the time it’s gonna work out no matter what you do?” I said, “So don’t lose too much sleep over this.” I said, “Go with your gut.”

If it’s 1% versus 8%, you know, then it’s different. But when it’s really, really small numbers, it doesn’t matter to the individual, it matters to the population. And so I try to help them not worry too much about the decision because it won’t matter for almost everybody, and they have to do…I’d say you have to sleep at night. So whatever’s gonna make you sleep at night, that’s what you should do. Because you have to live with yourself the rest of the pregnancy, so pick that one. So, again, you have to break it down in a way that’s sort of manageable for people.

Emily: All right. Well, I just wanna end, Nate, by saying thank you. As I said at the top, I don’t like group projects, and doing this group project with you was just a treat, and I’m really grateful we did it together.

Dr. Fox: Well, now it’s my turn. I have to say, I got turned on to Emily from reading your book, “Expecting Better,” which was recommended by a patient. I never read pregnancy books, ever. Why would I ever read them? I’m like, “This is ridiculous.” I read yours, loved it, loved it. Cold-called you, said, “I’m a guy in New York. We have to meet.”

Emily: “Let’s be friends.” We had lunch.

Dr. Fox: Yeah. And just in general, before we did this book, you’ve been so, like, friendly and gracious, and we’ve had a great relationship. And as your fame has grown, you never sort of, like, ditched me or dumped me. Like, we always maintain that relationship, which I appreciate that. But then also, when we decided to write this book…like I said, you’re a well-known author. You do this, you’re very, very good at it, you’re very successful. A lot of people listen to you.

And you could not have been more gracious in doing this in a way that made me feel like a partner, you know, even partners, whatever you wanna say it is, like, that we worked together on this, and I really, really enjoyed it. I learned a tremendous amount from you and from the process. I’m very proud of the book. Really, like, I’m proud of it. I think what we did was great. I think it’s gonna, hopefully, help a lot, a lot of people. I’m going to, again, display it proudly. And it’s really something I’m gonna cherish that we did for a long time. That’s great.

Emily: Me too. Thanks, Nate.

Dr. Fox: Thank you.

Emily: “The Unexpected: Navigating Pregnancy During and After Complications” is out April 30th, 2024. You can get it anywhere that you buy books. ParentData is produced by Tamar Avishai, with support from the ParentData team and PRX. If you have thoughts on this episode, please join the conversation on my Instagram, @profemilyoster. And if you want to support the show, become a subscriber to the ParentData newsletter at parentdata.org, where I write weekly posts on everything to do with parents and data to help you make better, more informed parenting decisions.

There are a lot of ways you can help people find out about us. Leave a rating or a review on Apple Podcasts. Text your friend about something you learned from this episode. Debate your mother-in-law about the merits of something parents do now that is totally different from what she did. Post a story to your Instagram, debunking a panic headline of your own. Just remember to mention the podcast, too. Right, Penelope?

Penelope: Right, Mom.

Emily: We’ll see you next time.

[00:53:41]

[silence]

[01:35:39]

Nate, are you okay? I know it’s 12:02. Are we, like, keeping you from doctoring? It’s in the chat.

Nate: [inaudible 01:35:50].

Emily: Okay. We’re just gonna read this, right? All right. Okay. I’m gonna read the part that’s not in green, right? I guess. Hi, it’s Emily. Here’s a piece of data for you. About 50% of all pregnancies include some type of complication, whether that’s a miscarriage, preeclampsia, preterm birth, postpartum depression, or other. I’m not saying this to scare you, but the reality is that we don’t talk about these complications very often, and yet they affect an enormous number of people. That’s why I’ve teamed up with Dr. Nathan Fox to write a new book called “The Unexpected: Navigating Pregnancy During and After Complications.”

[01:36:39]

[silence]

[01:37:04]

Dr. Fox: Are you gonna share the screen? I got a few more minutes, that’s fine.

Emily: Mainly I just share how to have more productive conversations with your [crosstalk 01:37:10].

Dr. Fox: The link. So I pulled a link, that’s what I have to read?

Emily: Data will help. But to make these hard talks…

Dr. Fox: Okay, I got it.

Emily: …as useful as possible, you need a script and a way to structure the conversation.

Dr. Fox: I’m gonna switch Nate for Nathan. Is that okay? Okay.

Emily: And above all, we hope it helps pregnant women feel less alone and more informed and prepared for whatever the future brings. You can order “The Unexpected” now wherever books are sold. Do you want me to just read the “Hi, I’m…” So, Nate, I’m just gonna read “Hi, I’m Emily.” I’m just gonna read this stuff in green. And then you read your [crosstalk 01:37:45]…

Tamar: I am absolutely champing at the bit right now. Do you have a few more minutes?

Emily: Hi, I’m Emily Oster.

Tamar: Both of you?

Emily: Hi, I’m Emily Oster.

Tamar: Okay. All right…

Emily: Dr. Fox.

Tamar: …thank you for just explaining how you guys met.

Emily: Because we’re gonna make a house ad for you, and it’s gotta sound different because it doesn’t make sense for me to start with, “Hi, I’m Emily,” on a podcast that’s yours.

Tamar: [crosstalk 01:37:59] is, Nate, you’ve actually been on the podcast before, so maybe that [crosstalk 01:38:05] just change the direction a little bit.

Dr. Fox: Hi. I’m Nathan, or Nate.

Tamar: Just [crosstalk 01:38:08], you know, so that people don’t feel like [crosstalk 01:38:11].

Dr. Fox: “The Unexpected” is a book we hope no one needs to read, but we also want everyone [crosstalk 01:38:13].

Emily: That’s why I’ve teamed up [crosstalk 01:38:12].

Tamar: But yeah. And just, like, the last time I was here, you talked about the ARRIVE trial but now, you’re gonna talk about something else.

Dr. Fox: It’s [crosstalk 01:38:14] pregnancy complications from first trimester to postpartum. For each one, we try to answer a few questions. What is the risk of recurrence in a later pregnancy? What treatments might lower that risk?

Emily: All right. Thank you, Tamar. Wait, don’t leave. Don’t leave [crosstalk 01:38:29].

Dr. Fox: And how can you better prepare if it does happen again?

Tamar: I think that should be fine. I’m sure I can make some magic. Okay. And don’t let me forget that [crosstalk 01:38:44] once this is done.

Dr. Fox: It’s important to us that we bring these maternal health issues into the light so that necessary research and policy change can hopefully happen.

Tamar: But I had an idea. Emily and I didn’t actually get the chance to run through this beforehand. I apologize for that. So as I was listening, I was thinking, you know, there is this very valuable conversation that you both are having about the writing of the book, and especially about statistics. I think that’s great. One thing that…like, I think that people will still want a little bit more of the book’s content. You know, like, I have some questions…

Dr. Fox: Wait, why are we doing something green for my podcast?

Tamar: …about things to do with kind of unexpected, you know, issues. Like, could we try a little, like, rapid fire, you know, asking you guys some questions that are a little bit more specific, and we can decide whether or not we wanna use it? Like, maybe you can invite me in to ask some rapid-fire unexpected questions. And…

Dr. Fox: Hi. Nathan Fox.

Tamar: …you guys haven’t even heard them yet, so this is gonna be new. I mean, I was just going through a list in my head of, like, things that could have been pregnancy complications, turned out not to be, but they really freaked me out, like, one after another. Like, is that something that you guys could just answer for a little bit more content?

Emily: I would say just to answer. You know, like, even if it doesn’t address this, then at least the podcast does.

Tamar: Okay.

[01:40:24]

[silence]

[01:43:16]

Well, actually, wait, just also quickly, how’s that? And just also, like, for the sake of ease, you wanna just say, like, Emily, like, “Okay. So we’re gonna actually test this out, kind of have the rubber hit the road. I’ve invited my producer, Tamar, in to ask some questions that we haven’t seen.”

Emily: Hello.

Tamar: Great. Okay. Let’s just go through the house ad. I have the link here. Okay. Sorry. Yeah. Yeah. Oh yeah, absolutely.

[01:44:18]

[silence]

[01:46:13]

Okay. Emily, can you just read, “That’s why I’ve teamed up with Dr. Fox?” Great. Nathan, it’s just like, “Hi, it’s Nathan.” Perfect. Thank you, guys.