Expecting Better: Why the Conventional Pregnancy Wisdom Is Wrong--and What You Really Need to Know

Oster weighs the decision to get an epidural by presenting clear, comparative evidence on its benefits and risks. She traces the historical evolution of labor pain relief, from Queen Victoria’s chloroform to modern epidurals, and then focuses on the epidural’s dominance in US hospitals, with usage rates as high as 90% in some settings. While acknowledging its unmatched effectiveness at relieving pain, she examines randomized controlled trials comparing epidurals to narcotics, concluding that the decision comes down not to the baby’s safety but to how parents want to experience labor.

Oster finds no major harms to the baby, as APGAR scores, NICU admissions, and breastfeeding success are largely unaffected. However, epidural-related maternal fevers can lead to unnecessary newborn antibiotic treatment. For the pregnant individual, the trade-offs are more pronounced: increased use of forceps or vacuum delivery, longer pushing times, higher rates of maternal fever, and a marginally higher likelihood of emergency C-sections for fetal distress. The procedure also raises the likelihood of requiring Pitocin and of temporary immobility post-delivery.

Oster evaluated the evidence and opted against the epidural for her own delivery but highlights how the same data led her friend to choose the opposite; both were satisfied. This framing reinforces her central thesis that evidence empowers personal choice. The chapter challenges one-size-fits-all recommendations and underscores that childbirth decisions, when grounded in data and aligned with personal priorities, are rarely right or wrong—just thoughtfully made.

Oster explores childbirth decisions through the lens of data and personal experience, challenging rigid approaches to labor, both natural and conventional. The chapter begins with her choice to forgo an epidural, which becomes a gateway to questioning other standard interventions like episiotomies, continuous fetal monitoring, and food restrictions. Rather than aligning strictly with either the natural childbirth movement or standard hospital protocols, Oster argues for an evidence-based, middle-ground approach supported by clear reasoning and clinical studies.

Oster draws on randomized controlled trials and historical medical data to evaluate each practice. She questions outdated norms, like food bans based on 1940s anesthesia risks, and critiques the near-universal use of continuous fetal monitoring, which increases intervention rates without improving outcomes. She supports the use of Pitocin post-delivery to prevent hemorrhage but warns against routine episiotomies, citing evidence that they cause more harm than benefit. A key strength of the chapter lies in how she balances data with lived experience, such as hiring a doula (which she validates through studies showing reduced C-section and epidural rates).

The chapter is rooted in a Western, medically literate, middle-class context and assumes access to hospital care, informed OBs, and birth planning resources—an implicit bias that may limit its direct application in lower-resource or culturally different settings. However, its advocacy for informed flexibility is broadly relevant, especially in highlighting how medical practices often lag behind available evidence. Though written in the early 2010s, the chapter critiques protocols that remain common, pointing to a continued disconnect between evolving evidence and institutional inertia.

Oster examines the immediate post-birth decisions parents must make, such as delayed cord clamping, vitamin K shots, eye antibiotics, and cord-blood banking, through the same data-driven lens she applies throughout the book. She challenges readers to move beyond default practices and understand both the rationale and trade-offs behind each intervention.

Oster presents current research and historical background to help demystify medical routines. She supports delayed cord clamping for preterm infants due to strong evidence of reduced anemia and transfusion needs and cautiously considers its use for full-term babies by weighing increased iron levels against a small risk of jaundice. She endorses vitamin K supplementation despite past controversy; Oster references early studies suggesting a link to childhood cancer but shows how larger follow-up research and decades of clinical practice refute these claims. Similarly, while acknowledging that eye antibiotics may now be less necessary due to prenatal STI screening, she explains that they remain legally required in many states. Cord-blood banking, meanwhile, is framed as a service with minimal benefit for most families; Oster highlights the low probability of private use and recommends public donation as a more impactful option.

Oster approaches these post-birth decisions from within a well-resourced medical setting, where interventions like vitamin K shots, eye antibiotics, and cord-blood banking are routine. This framing reflects a context where patients can ask questions, weigh risks, and even opt out—an experience not universally available. Nonetheless, the chapter’s value lies in how it encourages parents to understand the evidence behind these practices rather than passively accept them as defaults.

Oster explores the debate around home birth, weighing its potential benefits against its risks using a mix of data, personal reflection, and broader social context. Responding to arguments popularized by films like The Business of Being Born, Oster acknowledges the appeal of avoiding medical interventions but cautions against romanticizing the idea that birth without hospitals is inherently better.

She draws from her experience in low-resource settings, like Nepal, to show how hospital births dramatically lower maternal and infant mortality, highlighting how access to emergency care, antibiotics, and skilled staff saves lives. Yet she recognizes that in high-income countries, where backup care is close at hand, the debate is less clear-cut. Oster cites studies comparing planned home and hospital births, noting that home births are associated with fewer interventions (e.g., fewer C-sections and episiotomies) but potentially higher infant mortality, though the data are mixed and inconclusive due to methodological issues, including small sample sizes and confounding factors.

Oster emphasizes that home birth is only a viable option for low-risk pregnancies and should be overseen by highly trained professionals, preferably certified nurse-midwives. The chapter’s practical value lies in its sober reminder that while hospital protocols can be frustrating, the risks of being far from emergency intervention, however small, must be seriously considered.

Oster places the home birth discussion within the US healthcare system, where hospital births are standard and home births remain rare and somewhat controversial. She contrasts this with both low-income countries, where hospital access clearly improves outcomes, and countries like the Netherlands or the UK, where home births are more accepted and integrated into formal care. This comparison helps highlight that the risks and benefits of home birth depend heavily on context, both medical and cultural. Rather than offering a one-size-fits-all answer, the chapter urges readers to weigh evidence alongside the realities of their local care systems.