In ‘The Unexpected,’ Emily Oster tackles the emotional toll of difficult pregnancies

Illustation of a sad pregnant woman who needs prenatal care and support. A young woman expecting a child is depressed. Psychological and medical vector illustration. A pregnant woman wearing blue looks downcast. Her hair spreads behind her, filling the frame. — Mary Long | Getty Images

Economist Emily Oster made a name for herself using data to tackle big questions about pregnancy in her 2013 blockbuster book “Expecting Better.” Now, she’s returning to the topic with a book on how to navigate difficult pregnancies and serious medical issues.

“The Unexpected: Navigating Pregnancy During and After Complications,” which came out this week, describes conditions such as miscarriage, preterm birth, preeclampsia and postpartum depression.

It lays out research on how to minimize risk during the next pregnancy. And it explains how to have productive conversations about these topics with your doctor. The book is co-written by Dr. Nathan Fox, who specializes in high-risk obstetrics.

Oster says she was inspired to write the book after hearing from “thousands of women about their pregnancy complications. They were scared, anxious. They wanted to understand them better, what to do next time.”

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Emily Oster an economist and the co-author of The Unexpected: Navigating Pregnancy During and After Complications.
Photograph by Aisha McAdams; Cover: Penguin Press

According to Oster, 50 percent of pregnancies will involve or end in a complication. And for many people, that can determine whether or not to try to become pregnant again.

“When people have a complication, they feel they’re the only one,” says Oster. She hopes the book “helps people feel less alone.”

In an interview with NPR, Oster offers advice on how to handle the emotions of complex pregnancies and births. This interview has been edited for length and clarity.

You have a chapter on early miscarriages and whether or not you should share that information with friends and family. What are your thoughts on that?

The traditional approach is that you share information about pregnancy around 12 weeks. That’s a point at which the risk of miscarriage is lower. It also happens to be the point at which most people start to show.

Over the last several years, people have gotten more comfortable with sharing this information earlier. The question that a pregnant person should ask themselves: what is the support you’re going to want if you did have a miscarriage?

For some people, they aren’t going to want to talk to other people. For others, that kind of broader support is going to be very valuable.

Any advice on the dual feelings one might have about losing a pregnancy then getting pregnant again quickly after? How do you grieve and prepare for a birth at the same time?

Sometimes people have this feeling that if I get pregnant again quickly, then that’s going to make up for [the miscarriage] somehow — that it will all be fine. But part of being a person is to live with grief and joy at the same time.

You can be joyful about the baby that’s coming and still grieve the one who was lost.

There are a lot of different complications you write about in this book. Can you tell us about a couple of common ones?

One of the more common complications is preterm birth [babies who are born alive before 37 weeks of pregnancy, according to the World Health Organization]. What we talk about in the book is: How much does it matter when the preterm birth is? Is that likely to happen again?

There are also things that are more common than people expect, like vaginal trauma or prolapse [when one of the pelvic organs, like the uterus, bladder or rectum, slips out of place during the postpartum period, according to University of Washington Medicine].

These experiences can affect how women feel and can affect their reproductive health.

These complications can take a huge emotional toll, especially if this is your second or third pregnancy or if you have had a history of complications. How can you care for yourself in this process?

Radical acceptance of things we want to understand but don’t. When people have a miscarriage, most of the time they don’t know why it happened.

What we can do is accept that this bad thing happened and try to move forward with hope and optimism. That’s challenging. But if you can get there, it will help.

If you experience a complication during your first pregnancy, the question of whether or not to have another child can be fraught. So much of this book deals with coming up with a plan of how you’re going to talk to a doctor about this. Why is that so important?

In order to feel engaged with your own care, people need to have enough information to have a thoughtful conversation with their doctor. They need to have enough scripting to understand how to use the 15 minutes they have [with them] to get the answers that are going to matter for their [future reproductive health] decisions.

People often feel like they’re being asked to make decisions they’re not equipped for. And doctors often feel like patients are coming in with their own ideas about their care and not listening enough to their expertise.

What we need is an understanding of who is bringing what expertise to the conversation. The doctor is an expert in the medical side. The person can be an expert in their preferences and their values. We need to build better trust.

How do you talk to a doctor after a difficult birth? This is an incredibly hard conversation to have. You’re probably in a vulnerable emotional and physical state.

It’s hard for those conversations not to feel like a conversation about fault. Focus on the questions that need to be answered and are relevant to [future reproductive health] decisions: Why did this happen to me? What am I at higher risk for?

These questions should inform changes you could make in the future rather than [finding] fault. The more we can have early conversations with that frame, the better. But that’s very hard to do in situations in which people are tired and emotionally fraught. That’s part of the reason why you almost always want another person with you for a conversation like that.

What is the role of a partner in thinking about big questions and decisions regarding reproductive health?

Decisions should be made together. Having two people listen is better than one, particularly when it is about risk and things you're nervous or afraid of. A partner is another set of ears.

The digital story was written by Malaka Gharib and edited by Sarah Handel, Meghan Keane and Margaret Cirino. The visual editor is Beck Harlan. We’d love to hear from you. Leave us a voicemail at 202-216-9823, or email us at LifeKit@npr.org.

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