Episode 172 The Unexpected - A Chat with Prof Emily Oster

Ever wondered how to navigate the uncertain terrain of pregnancy complications with confidence? Join us as we welcome Professor Emily Oster, an economist from Brown University and a celebrated author, who brings her latest data-driven insights to the table. In this episode, we dive deep into her new book, "The Unexpected: Navigating Pregnancy During and After Complications," Co-authored with  Dr. Nathan Fox, an OBGYN. The book  shares personal experiences and valuable advice on preparing for medical consultations and understanding past pregnancy challenges. Emily's journey into the world of parenting data is not just enlightening but also empowering for expectant mothers aiming to make informed decisions.

Listen as we discuss communicating risks and probabilities effectively,  and transforming abstract data into meaningful, understandable information for patients. We also explore how USA and UK maternity care models differ. This episode is a treasure trove of insights for expectant mothers, healthcare professionals, and anyone passionate about enhancing maternity care.

Want to know more?
https://profilebooks.com/work/the-unexpected/
https://parentdata.org/
Instagram @profemilyoster 

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
Keeping my podcast running without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to support theobspod please head over to my buy me a coffee page https://bmc.link/theobspodV any donation very gratefully received however small.
Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...

Transcript

Florence: 0:00

Hello, my name's Florence. Welcome to the OBSpod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, anyone else that's interested, the OBS pod is for you.

Florence: 0:55

Episode 172 the unexpected a chat with professor emily oster. Today I am joined by emily oster, or professor emily oster, who is a professor of economics at Brown University in the US, and she's here today because she's author of several books and has a lot of interest in data and particularly parenting data, and she has a website called Parent Data and her own podcast. And we're here today to talk a bit about her latest book, the Unexpected Navigating Pregnancy, during and After Complications, which someone kindly sent to me to have a little read of. So, emily, welcome to the OBS pod.

Emily: 1:37

Thank you so much for having me. I'm delighted to be here.

Florence: 1:40

Would you like to tell my audience a little bit about yourself, because I do have some audience in all sorts of places, but I'm not sure how many I have in the States and they may or may not have come across you.

Emily: 1:53

Sure, so, as you said, I'm an economist. I'm a professor at Brown University, but I do most of my work these days translating data for pregnant women and for parents. I have four books. My first book, expecting Better, is about pregnancy. I have two books about parenting, cribsheet and the Family Farm, and then I have this new book which is about pregnancy complications, called the Unexpected, and I run a website called Parent Data which has newsletters and resources for parents who like to make decisions with data, which is my academic and expertise and my first love.

Florence: 2:34

So how did you get into the idea of data for parenting or pregnancy?

Emily: 2:41

I got pregnant is the short answer. No-transcript for myself, and that's the. That's the origin of the books.

Florence: 3:19

Excellent and the unexpected, talking about pregnancy complications. Why did you decide to write that? Because that's an unusual kind of topic to go with.

Emily: 3:38

So I wrote Expecting Better, which is my first book on pregnancy, about a decade ago, and since then I have had many, many conversations with people about their pregnancies, and some of those are like thanks so much for suggesting I can have sushi. But a lot of those conversations were about you know, this thing happened in my first pregnancy I had a miscarriage, I had preterm birth, I had preeclampsia, and I want to know is it going to happen again and what can I do about it? And so this book was one that I felt I wanted to give to many of the readers who had asked me those questions over time. And it isn't a book that I saw out there, it isn't a kind of resource that seemed to be available, and although I've said many times, I hope it is a book that people will not have have to read, I would like it to be there when they do need to read it.

Florence: 4:28

Yeah, I liked in the book you talked a bit about helping people with their future pregnancies but also being able to process and accept past pregnancy events, and that's something I see a lot as an obstetrician that perhaps people turn up in my antenatal clinic pregnant, having not necessarily resolved or understood what's happened to them before.

Emily: 4:59

Yeah, so in I mean, these complications are. They're complicated in many cases, and one of the themes that we heard both before and then after writing the book was people who said you read your book. I didn't understand what that was Like. I was just told this is what happened, but I really had no idea why it might've happened or would it happen again, or even what what had occurred, and so some of this book is about helping people understand what happened and then helping them have a conversation with their doctor about what does this mean for me going forward? Because actually a lot of the book is about facilitating those conversations and trying to help people get to a place where they feel heard and understood and like they're making choices that work for them that's why I thought it'd be really great to have a conversation, because I do a lot of work on trying to improve women's experience of maternity care.

Florence: 6:11

It's not just about did you have a caesarean or did you have a assisted vaginal birth or what happened afterwards. It's about how did you feel about it and what are the memories you have of it and a lot of psychological side of things. And a lot of what I try and do with this podcast is try and explain some complications or problems in a way that I might do if a woman was sat in front of me, trying to make it a bit more intelligible and get them to understand what's going on. So I felt like your book kind of really fitted with the work I'm trying to do. I like the idea of really preparing for your conversation with your doctor or in the UK that would possibly be also with midwives which come on to and not necessarily as common in the States. But tell me a bit about why you think that kind of preparation is so important.

Emily: 7:19

One issue is that our time with our providers is quite limited, and so I often feel, you know, if you had two hours to process something with your doctor, maybe you wouldn't need so much of a script and you wouldn't need to be so prepared, because you could just start talking and you would get there but and your doctor would have time to explain. Okay, here's what happened here, you know. But in the reality, where time is pretty limited, it can be very effective for people to have gotten enough understanding that they know what to ask and that they know that the conversation they're having is in service of answering questions that they need for decisions. Right, it's so easy to start these conversations with like why did this happen to me? So one of the things we talk about in the book is that question why did this happen to me? Where often people will come in with just like I want to understand why did a bad thing happen to me? And like the world can't answer that usually, and your doctor probably can't either.

Emily: 8:19

But, there's a way to frame that, to say, well, why did this happen to me? Are there things in my risk history? Are there things in the sort of medical circumstances that we should think about? For me, going forward question and turn it from a kind of existential, unanswerable question that's about basically grief into a question that's about how can I move forward in a way that is going to give me the best chance of a good outcome for the next pregnancy yeah, I liked the fact that you you actually wrote about having a script to have the conversation, and sometimes I have women that turn up with a long list of questions and and that's great.

Florence: 9:03

Actually, I really like that is it great it?

Florence: 9:06

is because, I mean, sometimes it's a little bit concerning because, like you say, I've got a time constraint and I look at the, the piece of paper, and I'm a bit like whoa, but it means they're gonna get from me what they actually need and what they actually are interested in knowing. Because when you have a conversation you never know. You make an assumption about what that person wants to know and what you need to tell them, but they may have something totally different on their agenda. So I do find it helpful when people come with their questions.

Emily: 9:42

I also think, just to add to that this situation can be quite scary for people, and so it's a hard environment to remember your questions. Yes, you come in. It's an expert. There's a little bit of a power imbalance. You're nervous, you're worried about what someone's going to say. To just imagine that you will remember all of your questions is unrealistic, and I think so many of us have had this experience of leaving and being like ah, I meant to ask this and it's right back in my head as soon as I'm out of the room. So writing things down is always a good plan.

Florence: 10:16

I liked your script because it was quite structured. Things down is always yeah. I liked your script because it was quite structured and I'm I'm different from you. I am not a data structure analytical person, so to have some kind of key anchors so you talked about the four f's and the four key questions kind of made sense to me and I liked what you said.

Florence: 10:38

I'm flicking through your book here because you said something about the first question of framing the question. Yeah, and it wasn't quite as simple as what. Why did this happen? Framing the question it was actually a bit more complicated than that in terms of you've written about clarifying priorities and framing the question about am I going to have a pregnancy now or am I going to have a pregnancy in three months or a year or whatever? That it's a different question and I hadn't thought about it like that. And that's I quite like that idea because sometimes I see people postnatally and they ask me when should I think about having another baby? Should I think about having another baby? Is it sensible for me to have another baby? And actually that's something I could relate to in saying, well, yes, but maybe in two years rather than yes, now. So I quite like the way you break that down.

Emily: 11:38

I think we have as, so this is a tool I use a lot when I talk about almost any decisions.

Emily: 11:40

So I quite like the way you break that down. I think we have as, so this is a tool I use a lot when I talk about almost any decisions, and I think it comes up very clearly here that when we are trying to decide about something hard, we have a tendency to to not go deep enough into what are the choices. So we just say, like, should I have another baby or not is actually not really a very answerable question, because it it isn't really the full set of choices, it's not really the thing you're choosing between. It would be, you know, you could ask should I have another baby now, or should I think about it again in a year? Should I have it? Like there are more concrete things and it's much easier to move forward on getting the information you need. If you've been clear at this first step in what's the question you want to answer, and even when you come to your doctor, you know, is the question like can I have another pregnancy safely today or can I have another pregnancy safely ever?

Florence: 12:36

Like those are sort of different questions and trying to understand what you're really wanting to answer can make things more productive yeah, I wanted to talk about how you make data make sense to people, because so this book is co-authored with Nate Dr Nathan Fox, who is an OBGYN in New York, and, like him, I have conversations every day about the, the chance. We tend to talk about chance rather than risk, now, the chance of this versus the chance of that, and and you know we use figures like one in 200 or half a percent, or how you kind of make data make sense to people and relatable to their situation.

Emily: 13:33

It's really hard and, in particular, making probabilities understandable to people in ways that are helpful for their decisions is one of the I think is such a big challenge and it's actually one of the things Nate and I talk the most about and maybe disagree a little bit about, in the sense that I think for him, when he talks to patients, he thinks the kind of most helpful thing is for people to understand sort of is this like very unlikely to happen again, reasonably likely to happen again, very likely to happen again? And kind of getting more specific than that is actually not helpful, Whereas I always want to be like well, is it 16% or 18%?

Emily: 14:15

And he's like as a patient, you know why would you care, and so we have a little bit of a difference there. But I think there is a sense in which, you know, people have a hard time understanding probabilities and some of what I like to do is try to frame the probability inside something that people would be more familiar with or would be more tangible. So the idea of you know something happening one in 200 times Well, how does that compare to the risk of a car accident? Or if this, if you encountered this risk every day for how many years would you expect before it happened once? Right, so sometimes that's helpful for people If you say you know this is a risk in one in, you know 3,600, like. Well, if you it happened every day, you face the risk, it would happen once every 10 years, Like.

Emily: 15:06

But the thing is everybody's a little different in what's helpful for them in terms of risk numbers. So often I'll try like six different things. You know, here's one version, here's another version and sometimes you'll be like oh, oh, okay, now I can understand, and it's particularly good for small probabilities where we get so focused on risks. Once you've sort of told me that there's any risk of something, it becomes very big in my mind and sometimes we need to back people out and say, okay, you know like, yes, that could happen, but you know you also could win the lottery, but but you're not buying lottery tickets.

Florence: 15:41

Yes and so yeah, no. That's a really good way of thinking about it, because we have this also, that sometimes we say okay, with an older mother, your chance of stillbirth might be double if you're in your forties compared with when you're in your 20s, but the still overall risk might be six in a thousand versus three in a thousand. So it's still very unlikely. But as soon as you say the word stillbirth, everybody's immediately you've lost.

Emily: 16:13

You say the word stillbirth and doubled in the same sentence like you've completely lost people exactly yeah, so I think how to have those data conversations is is really challenging.

Florence: 16:26

I also like the way you were explaining different uses of different data. So the example of recurrence chance from like big, the example of recurrence chance from like big lots of data, registry type data and I sometimes feel as a doctor it's almost like well, you can find out anything from that because you've got right hundreds of thousands of people.

Emily: 16:54

You've got everyone in, everyone in Scandinavia. You know everything about them for their whole lives. You you can answer any question about recurrence.

Florence: 17:02

Yeah, so that kind of gives you your recurrence, whereas whether something treatment wise actually makes a difference or doesn't make a difference, that kind of data is not helpful. You need much smaller and hopefully randomness controlled trial data, smaller and hopefully randomness controlled trial data. But even that in pregnancy is often really difficult because people don't like to do trials on pregnant women nope.

Emily: 17:28

So yeah, and our our data on many of the questions, these kind of causal questions, you know, if I treated this differently, if I did this, would the outcome be better? A lot, lot of our data on that is really poor because we don't have trials, we don't have randomized trials. Even if we have data that compares groups who were treated differently, it can be very, very difficult to know if that's the way the thing you did to treat them or if it's just that you know these groups were different in other, in other ways. And so our the kind of first piece about recurrence. We often know way, way more than the second piece about. You know what to what to do about it yeah, and I also like the simplicity.

Florence: 18:06

You were talking about modifiable and non-modifiable factors, because it's quite difficult for me when a woman comes and actually she's got something that I, I and she cannot modify, it's non-modifiable. We just have to deal with it, and that's quite a good way of thinking about it. That was new to me, which sounds really stupid. No, actually yeah, I find it interesting to kind of understand that mindset and it's like, oh yeah, I deal with that every day, but I've never thought about breaking it down into those two things.

Emily: 18:38

You don't think about it like that.

Florence: 18:40

Exactly so. That's great. I know lots of people get in touch with you. Do you find people do want to know detail? Because I know when I listened to your parent data podcast with Dr Fox, you had a little bit of a debate about whether people want to know detail or not, and you've also alluded to that, because we don't want to overwhelm people, do we? But the people that get in touch, with you?

Emily: 19:08

do they generally want detail? Yeah, I think, yeah. So I think, in some ways, nate and I's disagreement about this is because the people who write to me they wanted to know the details, like that's, that's what they're looking for here, and I think for a typical patient, it's more varied. There are definitely people who find you know, really detail-oriented data stuff to be in some ways reassuring, and then there are people who say you know, like I want to know what I can do, or I want to know things that are relevant for my decisions, but I don't need to know every tiny piece of data, like that's not going to help me, and I I think one of the challenges that I I don't envy you, but one of the challenges as an actual practitioner is figuring out which, who, who is what person like, which is the person who really wants to know every detail and that's going to make them feel better, and which is the person who is more comfortable not being quite so in the weeds.

Florence: 20:02

Yeah, and that often you can get a sense of that from a conversation. But also sometimes I just ask people are you a really detailed person or are you not a really detailed person? What would you like me to tell you? And we've recently switched to electronic consent forms for cesarean birth and that's very detailed and they have to click through a whole series of screens. And some women have said to me no, I don't want to read all this. Thanks, just tell me the key things that I need to know. I don't want to read all this. Thanks.

Florence: 20:35

Just tell me the key things that I need to know. I don't want to know there's a small risk of, I don't know, hysterectomy or you know, because that's absolutely terrifying at a point when you're having a baby so you've got to try and tailor it, but it's, it can be challenging, I think it varies for many people depending on getting back to the modifiable versus not modifiable.

Emily: 20:57

Like the thing that's that's tough is kind of being told like there's nothing you can do about it. It's like it's this risk, small risk of this terrible thing and there's absolutely nothing you can do about it. Why do you tell me yeah, like what, you know like what. And for some people it's like you know, I want to be prepared. And for some people it's like you know, I want to be prepared, I want to be able to kind of put in my head like what would I do with that? But if I think, for many more people, even people who like detail, sometimes it's like well, I wasn't good, that's not action, it's not action oriented. You're just trying to scare me.

Florence: 21:26

And that's comfortable, or it's that medical legal thing of yeah, we just don't want you to say that we didn't tell you exactly right.

Emily: 21:32

You could grow horns. It hasn't happened. But you know we just want to be. If you do grow them, it will not be a result of us yeah, yeah, I listened to your podcast with Senator Samra Brouk about doulas.

Florence: 21:51

Yeah, I absolutely loved it she's amazing.

Florence: 21:54

I love, I love both of you yeah, I love both of you the passion you had for doulas and the evidence for doulas, and so part of me was kind of, oh my god, we don't pay for doulas on the NHS, so we're behind. But I did think well, but we have midwifery led care, for which there is lots of data, and I was interested because I think you said in the book only about eight percent of births are midwifery care in the US at the moment, and so I wondered if that was something that frustrates you or that you kind of feel the data is there for but isn't happening yeah.

Emily: 22:37

So it's gone up a bit over the last, maybe even five years and it's like edging closer to sort of 10 11, which is good. But I think that you're this is a piece that I think I and many other people find frustrating, because we do have quite a bit of evidence that the midwifery care model is at least as good and probably in many ways better for outcomes, for at least you know, and OB is also an option, but isn't the default. I think there are a lot of people who think that that that model should be where we are going here, and it's interesting because it's the model is. It's so in some ways sufficiently unusual that people's perception of what that even means in the US is quite different. So if you tell someone you know I had a midwife, many people the first thing they will think is like oh you had an unmedicated birth in your bathtub.

Emily: 23:44

Like that.

Emily: 23:44

Midwife and home birth are like the same thing, even though you know, 90% of midwife birth assisted births in the US are in hospitals, so that is, in fact, the typical thing, but it's not what people have in their head, and so I think we need a little bit of a shift there, and in some ways, I think we're going to get it, because not for good reasons, but because of dearth of obstetricians in a lot of areas of the US, and so the midwifery care model is going to end up being a default in a lot of rural areas.

Emily: 24:18

About 40% of US births are paid for by Medicaid, which is the government coverage for people with lower incomes. Medicaid likes to pay for midwives because they're cheaper, and so my guess is we'll get a push just for those reasons. I wish we would get a push for other reasons. Yeah, and it's not. I mean, nate and I have talked about this a lot like cause. This isn't for everyone and it's not going to be for every birth, but I had a midwife with my second kid and I would recommend it to anyone.

Florence: 24:44

Yeah, it should be an option. I'm also interested in water birth, so I don't know if you. You saw there's just been a big study published um the pool study, about I'm trying to remember how they call it um, it's not that water birth is better, it's it's a double negative, it's not worse, right?

Emily: 25:06

I remember there's like a worse, exactly not inferior, kind of that's it?

Florence: 25:10

yes, and water birth is something there's. There's a bit in the UK. It's not as much as there could be and we want to improve it, but is there much water birth in the US or that's kind of?

Emily: 25:24

I mean, that is much more something that would happen mostly at home or in a birthing center. So actually I gave birth in a birthing center, in a hospital, and there was a tub, but you could not give birth in the tub, right? So when the baby was going to come out, well, like at the pushing phase, you had to get out of the tub, yes, which was bad yeah, yeah, so I think we haven't that.

Florence: 25:45

That's another thing that might come, because, yeah, I went to this conference a couple of weeks ago and they were midwives from Australia and they said, well, obviously we have 14 pools because we have 14 birthing rooms and and we were kind of sorry, you have one in every room, you know we're, we're very excited when we have a couple. So, uh, I can see like they're clearly one extreme and and the US is where the other?

Emily: 26:13

yeah, yeah, yeah, I mean it's very. There are a lot of very interesting conversations here happening now about these, about these issues, even in concert with some of the discussions we've had about our terrible maternal mortality statistics, and you know how much of this is. People are not being heard and the model that we're using for birth care, you know, needs to be fixed in some in some deep-seated way yeah, I think it's really interesting because it's all the same problems, well, worldwide.

Florence: 26:46

I mean, I know, yes, your maternal mortality and morbidity is worse than ours, but I don't know if you've heard. There have been multiple maternity scandals in the UK and it's it's always about not listening to women and them not being heard. I'm conscious we're about to run out of time. I I think there's kind of two, two things. One is I didn't know if there was anything you wanted to ask me as a UK obstetrician what do you think?

Emily: 27:17

I do have question, which is you know a little bit maybe from reading a book from sort of here, like what is the other than the midwife, the midwifery model? What is the biggest difference in pregnancy care?

Florence: 27:32

that's difficult because it is really the midwifery model, I think. The other thing might be scanning. I think I think we're most women will have a scan at 12 weeks and a scan at 20 weeks. We won't routinely do third trimester scanning. We love scanning.

Florence: 27:57

You can get you know you can have like an ultrasound at the mall yeah, exactly, people like to go to the mall for ultrasounds so I think I think that's probably the other thing, because you you talked a bit about maternal fetal medicine specialists and we do have those, but it more be you'd have your pregnancy care with them if you were complicated, rather than go to them for a consultation and so on. But yeah, I think I think that, and the midwifery led care, I think we're a bit more low tech, maybe for a better word bit less.

Emily: 28:33

I mean, it's sort of the same bit less medical.

Florence: 28:35

Yeah, exactly, yeah, yeah. And finally, I try and end my episodes with a zesty bit, a kind of bit that you kind of want people to remember from the conversation we've had, or to remember from, you know, your book or anything else. What would you, what would you say your zesty bit might be?

Emily: 29:01

Oh my gosh, you know I this isn't zesty, but the thing we just want people to get out of this book is that you're not by yourself and that's not zesty, but it is. It is really. The message here is just you're not, you're not alone, and I think pregnancy complications can be really isolating and I would like people to understand that they're not doing it by themselves.

Florence: 29:27

That is perfect, because I think what I mean by zesty is, like the essence, the tiny little bit that you're going to take away and not like a hot.

Emily: 29:37

It's not a, you don't mean like a hot take no, exactly it has to be.

Florence: 29:42

It has to be yeah, and I think you're not alone, that is. That says it all. I think that's a really great place to leave it.

Emily: 29:50

So thank you so much for coming on, so much it was such a treat.

Florence: 29:56

So thank you so much for coming on so much. It was such a treat. I very much hope you found this episode of the obs pod interesting. If you have, it'd be fantastic if you could subscribe, rate and review, on whatever platform you find your podcasts, as well as recommending the obs pod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalogue from clinical topics, my career and journey as an obstetrician and life in the NHS more generally.

Florence: 30:29

I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary.

Florence: 30:53

If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes, where I've attached some links. If you want to get in touch to suggest topics for future, you can find me at TheObsPod, on Twitter and Instagram and you can email me theobspod at gmailcom. Finally, it's very important to me to keep TheObsPod free and accessible to as many people as possible. Accessible to as many people as possible, but it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and by chance, you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link going and keep it free via my link to buy me a coffee. Don't feel under any obligation, but if you'd like to contribute you now can. Thank you for listening.