Emily Oster’s Expecting Better, Part I: Prenatal Screening’s Panicky Reassurance

Emily Oster is an economics professor at the University of Chicago who recently published her take on pregnancy, Expecting Better. In the promotion of the book, along with drinking during pregnancy and bed rest, prenatal testing is one of the highlighted points where Oster’s book promises to buck conventional wisdom. Her experience with prenatal screening shows no matter how much information you seek beforehand, the expected reassurance isn’t always expecting better.

Oster explains to her students that microeconomics is about making decisions. She distills the components for making a good decision down to two factors:

1. Having all the information about the decision; and,
2. Weighing the pluses and minuses (costs/benefits in economics terms) based on personal values.

Oster emphasizes that this isn’t just one way to make a decision: “It is the correct way.”

Regarding prenatal testing, Oster describes it as the “one major medical decision” to be made in the first trimester. In the introduction, Oster admits:

I’ve always been someone for whom knowing the data, knowing the evidence, is exactly what I need to chill out. It makes me feel comfortable and confident that I’m making the right decisions.

So, for the second factor in making a good decision, Oster’s personal values is to be comforted by knowing the data and she views prenatal testing as promising to provide data on the health of her child. But, she is frustrated in getting the data about prenatal testing.

Generally, Oster was hoping for a doctor trained in decision making, but discovers that this isn’t the focus of medical training. And, for that, she is grateful when it’s time for a doctor to call upon her training to deliver the baby, but medical training “doesn’t leave much time for decision theory.” Instead, in the context of prenatal care, Oster realizes that she “had the appearance of decision-making authority, but apparently not the reality.”

The impetus for Oster writing Expecting Better was her frustration at not having an easy way to get the data to make her decision. For example, when trying to understand the complexity of the probability recalculations provided by prenatal screening, it took Oster an entire weekend to comb through the data. Even after meeting with a genetic counselor (an option not available for many women before accepting testing), Oster still did not feel satisfied at the level of understanding provided about prenatal screening.

Through her own research, Oster gains an understanding of what a screening result would tell her about her chances for having a child with a chromosomal condition. Oster shares how others had told her they would forgo prenatal screening because a “bad” result (Oster’s description) would just make them worry. Oster’s response, “A thoughtful view, if not ours.” Ultimately, because of the lack of risk to the pregnancy, and because Oster believes that prenatal screening “provide[s] a lot of information,” she and her husband have first trimester prenatal screening.

Here’s the result of Oster using the “correct” way for making a good decision by finding the data and deciding based on her values:

The testing went well, we stopped there, and Penelope was born healthy. I’m still not sure it was the right choice. A few weeks after the test I called Jesse in a panic, convinced I couldn’t live with the remaining risk. I needed to know for sure. He talked me down, reminded me why we made the choice, and told me I could change my mind and get amniocentesis later if I didn’t feel better. I eventually relaxed. But next time, if there is a next time, I’ll do the CVS.

So, even after spending a weekend, having genetic counseling, and having the academic training in how to make decisions–even with all of that–Oster had the experience she dismissed: of having a screen result that was supposed to provide reassurance but anxiety still persisted.

In Part II, we’ll examine Oster’s conclusion that next time she would have CVS.

Oster’s experience with prenatal screening is a common one: seeking reassurance but still having anxiety after a result. What experiences are you aware of with prenatal screening? Did it provide reassurance or did anxiety persist?