Book Review: Expecting Better

I have been excitedly waiting for the opportunity to read Emily Oster’s book Expecting Better ever since I read an interview with her on it. I think I was the first person to check it out from our library, and once I got it I read through it very quickly.

She actually starts out by looking at information about conception, including the effect of the pill on fertility, fertility awareness, and whether it is possible to influence a child’s sex by timing intercourse. I personally think she could’ve gone a little deeper on the effect of the pill or other hormonal methods on fertility, but I understand why she didn’t. She was looking at how long it generally took for a woman to have a cycle after discontinuing hormonal contraceptives, as that was of the most interest to her personally, so I can understand why she didn’t look at long-term effects on fertility. It may also be that there simply isn’t data on that. As a practitioner of a mucus-only method, I disagreed with her discussion on cervical mucus, but it should be noted that she was talking about the mucus observations as she learned them in Taking Charge of Your Fertility, which uses a sympto-thermal method. Mucus observations are very different between different methods, but the main mucus-only methods (Billings and Creighton) do not use internal checks for mucus. This eliminates some of the “ick” factor she mentioned. With Billings, you don’t even have to touch or look at anything necessarily.

Then on to the various pregnancy items she tackled. I found these sections to be very well-done. She meticulously combed through the available studies and evaluated the data to determine the real risks and benefits of various things from alcohol in pregnancy to prenatal testing. There are some things I wish she had addressed, such as testing for and management of GBS and GD. Evidently it didn’t occur to her friends or her to question these, and, to be fair, I doubt I would’ve occurred to me had I not been pregnant and given birth in two different countries that have very different protocols for these things. The things she did cover, though, were thorough and interesting, and I enjoyed reading it even if we had different outlooks on some things (I prefer to decline prenatal testing, for example, but it was still nice to know the real numbers behind it).

The final section is about labour and birth. Here is where I found myself not enjoying the book as much, and not because she and I have different views regarding these things. For example, when she spoke of membrane sweeping to induce labour, I wasn’t sure of her assertion about how well it works. I decided to look at the study she referenced, which is a Cochrane review. The review stated that 8 women must have this procedure to prevent 1 formal induction, and the authors concluded, “Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women’s discomfort and other adverse effects.” So, on the one hand she’s right in that there is a reduction in formal induction, but it isn’t exactly foolproof.

I also found myself questioning her assertion that induction is necessary if the waters have been gone for more than 12 hours before labour begins. The study she cites (another Cochrane review) actually only assesses those who have their waters go prior to 37 weeks, which would seem to make a difference to me. Even so, the author’s conclusion stated that there was no difference in outcome for the baby if they waited or delivered, as Oster notes; there was an increased risk of c-section to not waiting and an increased risk of maternal infection, with a longer hospital stay, to waiting. Oster herself comments that the increased infection rate was at least partially due to internal exams, so that part could be minimized by avoiding such exams. Personally, having been through a major surgery (not abdominal, but major), and a postnatal infection, and given my allergy to local anaesthesia, I’d choose expectant management even with the increased risk of maternal infection. But it’s good to have all the data and make a decision from there, as Oster definitely advocates.

I also found myself questioning her conclusions about the epidural. She comments that there is no adverse effect on breastfeeding and no increased lethargy, yet from the abstract all it mentioned was APGAR scores. While it is certainly reassuring to know that APGAR scores are not adversely affected, I’m not sure how that says there’s no adverse effect on breastfeeding. Perhaps that is mentioned in the full review, though. I do know that a different study I’ve seen that found no adverse effect on breastfeeding only compared having an epidural with having an opiate, so that isn’t conclusive. I was a bit surprised she didn’t look more at adverse effects from unnecessary antibiotics given because of maternal fever from the epidural.

My main critique, though, was with the discussion of the events immediately after the birth. She discussed pitocin, delayed cord clamping, and vitamin k, but only separately. In fact, these are interrelated, as most guidelines I’ve seen caution against using pitocin with delayed cord clamping. More doctors and medical associations are now recommending delayed cord clamping as the norm, too. So I’d have liked to have seen more on that. I did like her discussion of the eye drops, though again I think she could’ve spoken more about possible risks.

All in all, I think this book is important. Especially for the sections on pregnancy, this book should prove an invaluable resource for pregnant women. Doctors often haven’t the time to go through all the data and a risk/benefit analysis, so this book can help by providing a discussion of the studies. Even with my critiques of the later sections, providing the studies is quite helpful. Above all, this book provides an excellent example for how to approach the medical decisions of pregnancy (and otherwise).


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