Monday, 21 October 2013

Book Review: Expecting Better

Economics professor Emily Oster got pregnant, then she got very annoyed, and then she wrote a book about it. The result is Expecting Better. A pregnancy book which, refreshingly, expects it's reader to still have a functioning brain.

Society has (mostly) moved on from treating all women as stupid, or at least doing so openly is now non PC. However, it sometimes seems like this doesn't apply when the woman is pregnant. Official medical guidelines are frequently so over cautious that they seem to treat expectant mums as little more than irresponsible foetus carrying devices. While the natural birth lobby insists that these poor vulnerable females will plunge into a spiralling cascade of unwarranted medical interventions and "unnecaesareans" at the merest mention of a negative "birth story". (sorry excessive use of " " there, too many silly phrases!). So Oster's approach is very welcome in that it starts by assuming the reader still has a brain.

Rather than just trotting out the conventional pregnancy "facts" like a million other books. It aims firstly to give the reader a method for determining how reliable these facts actually are and secondly a means of using this knowledge to make decisions for their own specific situation. I'm right behind this idea. There is surprisingly little good data about many aspects of pregnancy and birth, but there is a heck of a lot of dodgy studies, made up stuff and outright woo. Even where high quality studies are available there is rarely a single right or wrong answer to any decision. Take epidurals for example. Should you choose to have one in labour or not? One woman may decide that she'd prefer to avoid it as they increase the likelihood of an instrumental delivery, the Mum in the next room might decide to have one because nothing very bad is likely to happen and they make the really really hurty thing stop hurting. When based on the best available evidence these are both perfectly logical decisions. Yet I have UK friends who have felt they had to apologise for having an epidural and justify the need for one beyond just wanting the pain to stop (such is the pressure to avoid one in certain circles here). For Ostler the opposite was true and not wanting one in the US was seen by some as wrong mostly just because it was unusual.

This conflict between the UK and US experience of birth brings me to a major concern with this book. Overall I really rate it. However, despite this being a UK edition, it is clearly based on Ostler's experience of having a baby in the USA. Standard policy is often very different between the two countries and anyone who has had a baby on the NHS is likely to be utterly horrified by some of what is in this book (not being ALLOWED to eat or drink anything when you've been in labour for days?? wow). There are a lot of examples of doctors insisting on policies which are at best overly cautious and at worst potentially harmful and many that are based on no good evidence at all. As someone who has already had two babies in the UK, these sections made me feel incredibly grateful for the NHS. But there is a risk that first timers reading this, perhaps before they've had any dealings with medical professionals (it's common not to see anyone before 12 weeks), will go into their first appointment needlessly spoiling for a fight. In the US perhaps this would be justified, but over here many of the major issues in the book just won't come up for a low risk pregnancy. In fact if everything is low risk and normal you may never see a doctor at all as midwife care is the standard.

Another problem is that, as I mentioned above, misinformation doesn't only come from doctors. Ostler touches on this but only barely. I've come across a lot of natural birth advocates who would gladly pump you up for a fight with the doctors, despite having no good evidence for their argument either. The dominance in this book of the problems with conventional medicine could potentially form yet another science bashing stick. I doubt this was the authors intention and the same methods of appraising data and making decisions could be applied to alternative advice, but I'd have liked a bit more balance.

Finally, most women, even the smart ones, won't have a professional background in analysing statistics. They won't have access to the many scientific papers that are published in subscription only journals and they probably won't have the time to analyse everything in this depth anyway. However, the principle that women should be able to question what they are told and make the decision that is best for them is an important one. Even if most only actually do it for the one or two things they really care about.

The good thing about this book is that it is a starting point. It says that it's not ok for pregnant women to be treated like idiots. This won't be the new pregnancy bible for first timers and a lot of what it says needs to be treated carefully in the UK. However, encouraging parents to take an active and informed role in decision making is important. Hopefully this book will be followed by others* which are more appropriate for the UK and which also cover alternative / natural birth advice and the post-birth minefield too. Hopefully it will also lead to more women knowing they can question those setting out the pregnancy rules, weather it's the obstetricians, the midwives, the NCT teachers or the know-it-all woman at the bus stop!

*I also recommend another recent book: Bumpolgy by Linda Geddes. Which uses scientific data to bust a whole bunch of pregnancy myths.

Disclaimer - I paid for my own copy of the book and as far a I know I have no connection to the author of anyone else involved with it.

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