Emily Oster

3 min Read Emily Oster

Emily Oster

Why didn’t you cover TFMR [termination for medical reasons] and other forms of pregnancy loss outside of miscarriage in The Unexpected? I was so excited to read this book, as I am a huge fan, and ended up feeling even more isolated when it wasn’t covered.

—Erica

Thank you for writing. First of all, I want to say I am so sorry for making you feel more isolated. Please know this was the opposite of our intention with The Unexpected

When we outlined The Unexpected, we used information about the frequency of various events in the population to make a difficult determination about what the chapters would cover. We started from an understanding that we could not address every pregnancy complication. We wrote the opening of the book as a general guide, in the hopes that it would help people who were experiencing complications other than the ones that we review in each chapter. Since the book has come out, there are several complications that many people have asked about, and we are discussing the possibility of including chapters on cholestasis and pregnancy after fetal anomaly when we update the book. 

patients waiting for checkup
RDNE Stock Project / Pexels

Although we discuss several forms of loss — miscarriage, stillbirth — we do not explicitly address termination for medical reasons. Nate and I both know that this experience can be horrible and, again, we are sorry the book made you feel more alone. TFMR is not a condition on its own, but there are a number of conditions for which it might occur, including maternal issues like heart conditions or severe preeclampsia, or fetal anomalies. We wrote the book with the intention of helping people navigate pregnancy following complications, and the approach in a later pregnancy would depend on the underlying complication that necessitated the termination. In the book, we include many of the conditions that might make this necessary, and for instance do mention termination as a possible response to severe hyperemesis. 

It is important to acknowledge here that — as we observe in the book — the Supreme Court’s Dobbs decision overturning Roe v. Wade renders this, along with many other complications, harder to treat, and harder to treat equitably across the country. It is devastating that in the midst of these fraught and sometimes life-threatening complications, prohibitions against using medical expertise and data as a guide makes receiving treatment much harder and pregnancy more dangerous.

Whatever the reason for your termination, we hope the book might provide some guidance and support if you do choose to try again.

Thank you again for writing.

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teeb
teeb
19 days ago

I just wanted to echo the other excellent comments here and put in a strong request that TFMR be included in the future.

I experienced TFMR in the second trimester of my first pregnancy, as did one of my close friends. Although other complications are hard and important, TFMR is uniquely isolating and brings up many more complex feelings than complications that are not associated with a decision.

As a physician, I had access to lots of information and still found myself completely lost managing TFMR.

The exclusion of TFMR from your mainstream and important book only perpetuates the unjust feelings of shame and isolation most of us experience and that we are somehow less deserving of comfort or recognition than our friends and loved ones who deal with miscarriage.

Kate C
23 days ago

I keep going back and forth about what to write to you, Emily. I’ve read and admired some of your work in the past, and appreciate the common-sense, data-driven voice you bring to the topic of pregnancy. Somewhere along the way, I remember also reading your experience of difficulty as a public figure suddenly responsible for representing so many experiences and so many people. And I can feel your discomfort radiating through your responses to my friends and colleagues (as here) who have written to you. The last thing I want to do is shut you down in this conversation. You are not my enemy and I am not your enemy. I would love, in fact, to be your friend. But that is up to you.

My perspective is as a TFMR mom and a holder of Ending a Wanted Pregnancy support group, somatic coach supporting grief integration, and an activist educating on TFMR for over a decade. So I speak on my own behalf and also on behalf of my community of thousands of parents who have used prenatal screening information to inform interruption of their wanted pregnancies.

It feels to me that you’re avoiding talking about TFMR in your book because you don’t want to politicize your book. Perhaps you were even counseled on this by an editor. I am familiar with the perspective of mainstream editors on abortion. I can not imagine that you would have been counseled to exclude TFMR by your MFM coauthor — but stranger things have happened. And I sense that you’re getting rather bad counsel from a publicist at the moment. Truly, this response (and others to my personal friends and colleagues) feels like a tight-leash, tight-lipped PR cleanup. It isn’t serving you, nor is it serving the TFMR community you have excluded and disappointed. I am hoping we can melt the ice a bit and get to the heart of it, but I know you may shut that down.

The unrest is this: it doesn’t make sense to have omitted TFMR whole-hog (except in cases of HG — thank you for that! It’s VERY important!) from a book about pregnancy complications UNLESS you are actively avoiding it for some reason. Taboo is the most common reason abortion gets excluded on purpose. Nobody wants to be controversial. Ignorance is another reason — you might have all your information from the political discourse, which isn’t the truest source of information here as it’s ultimately propaganda. If you instinctively feel abortion to be controversial, you have likely internalized this political propaganda. Placating your funding sources feels like a possibility. I don’t know what your reasons are, and you don’t have to tell me, but there ARE reasons, and rarity isn’t one. TFMR is COMMON among the subset of pregnancies that encounter complications. For my daughter’s diagnosis (which I don’t expect you to cover specifically), well over 90% of parents choose to interrupt their pregnancy. For many milder diagnoses, the numbers are still majority TFMR. If you talk about prenatal testing, it is a deafening silence to leave out WHY we gather data. We gather data to have choices and autonomy over the health and lives of our children. You know that. That’s why you yourself partook of prenatal screening in your own pregnancies. We all have our limits, and prenatal testing helps us understand if we can meet our children’s specific needs with our limited resources, and it also helps us live by our own most personal values in difficult situations. For a large majority of families, TFMR can support our values in specific situations that only prenatal testing can give us. Not better or worse than any other paths forward, but certainly not so rare that it ends on the cutting room floor in a book about pregnancy going sideways.

I DO want you to fix this oversight with additions to your V2, and I am glad you’re considering it. However, if you were just to put pen to paper today for that, I wouldn’t trust you to do it well. In this particular answer, forgive me: it feels like the most basic man-splaining from someone on the outside of the situation we have lived ourselves and know inside. It won’t soothe the people you’ve upset. I was disappointed that you declined to talk with Erica offline, and I hope that you will reconsider that and talk to her or to me offline. I am happy to keep that confidential if that is what you need to feel safe enough to engage. Reach out any time: carson.kate@gmail.com

My worry is that you will say something like “you can talk to your doctor about your choices” when not everyone CAN talk to her doctor about her choices. In my 12 years holding space for TFMR, we used to very occasionally — like maybe once a year — see cases where a woman’s doctor willfully misled her about her pregnancy, for instance saying trisomy-18 is “no big deal, don’t do an internet search. We’ll see you for your normal checkup in a month” to purposefully push her past legal limits of abortion care. Now I see cases where I mistrust doctors’ intentions every few weeks. It sucks. It’s real.

I also worry that you might not want to touch this because the laws really are changing so fast, so fast that any specifics may go out of date by print time, but even as they change, there are some resources that remain trustworthy and work hard to keep up, for instance, the mods on reddit r/abortion are excellent at finding care and funding in real time, and the website ineedana.com responds nimbly to legal change.

I need you to understand the magnitude of the tabboo on TFMR parents, and how we can’t even necessarily trust our therapists and doctors to support us. I have held mothers who were kicked out of babyloss support groups because “you chose this.” I have known mothers whose therapists dropped them abruptly with a soliloquy about the importance of life and the wrongness of murder — and gave no referral. They did it as a punishment. This is therapist abuse, and it happens. I have known mothers who, as mentioned above, were pushed past their local legal limits on purpose (thus increasing risk to their safety) by doctors who were supposed to keep them healthy and safe. I’ve know women who headed into subsequent pregnancies only to get reamed by a nurse to whom they disclosed their past termination. We TFMR parents don’t — CAN’T! — trust just anyone. And I want you to be someone we can trust, but you’re not there yet. You’re not ready to write this today. Please DO accept the counsel of myself, my friend Dr. Erica Rosmid, The TFMR Psychologist, and others who have lived this experience and are eyes-on-the-ground of the moving landscape. I can recommend others. For instance, obstetrician Dr. Anna Igler of Wisconsin would be a great person for you to talk to. She has been public with her story and has both the medical experience and the personal experience that you can trust. Margot Finn has written extensively on this, and also holds space with me at EWP. Sabrina Fletcher, The TFMR Doula, is a great voice on the subject. T.S. Mendola is a reporter and an initiate of this particular abortion experience. Erika Christensen is an incredible activist and advocate and has a wide view on the issue of abortion in all trimesters (the 2nd and 3rd trimesters being disproportionately important to TFMR).

Please, I know it’s hard to receive this criticism I know it can sound scary and feel like a pit in your stomach to realize, upon the release of a book you poured so much into, that you disappointed an enormous group of bereaved parents without meaning to. I know how scary it is to even put a toe into the waters of abortion discourse in the US, for I have had to encounter a great many of my own fears on that path myself.

Please DO amend your book — but please let us help you. You’re not ready. You don’t know yet. Nothing you’ve written in response to this criticism shows that you know. We are here to teach you if you’ll have us. And I promise we are kind. We’ve experienced enough shame ourselves. We shouldn’t want to create any more. I hope I haven’t done so here. I really do get it: you only know what you know until life hits you over the head with it. My hit-over-the-head moment came at an ultrasound at 35 weeks. I’d like to help you understand what I know now but in a gentler way than that.

Thank you for engaging. Please reach out. I am just going to promise up front that I won’t share with anyone without your express permission, because I feel that privacy may be an important element of further productive conversation.

Thanks for reading. Here for you and for all the TFMR moms who are looking on.

emu147@hotmail.com
emu147@hotmail.com
21 days ago
Reply to  Kate C
21 days ago

Kate— ALL. OF. THIS. Thank you for being such a champion for the TFMR community.

Emily— I can vouch for the fact that Kate will listen to you and help you understand this topic in a kind, compassionate and open way. Why not have a conversation?

BostonMom
20 days ago
Reply to  Kate C
20 days ago

Thank you so much for sharing this, Kate, and for you and the parents who shared their stories in The Guardian. As a mom with two children and two miscarriages now carrying a fifth pregnancy, I find the silence around TFMR unhelpful, and information like yours extremely helpful. I want to know the context of all pregnancies and terminations, especially in an source like The Unexpected, and not just have this information on an “as-needed” basis. I, too, felt like the book should have a chapter on this and hope its in development and that Emily will consult you and the others you mentioned.

Liz
Liz
24 days ago

Hi Emily,
I’m a huge fan of your work and also a TFMR mom. I am also a data/science nerd and there is so frustratingly little data on TFMR. I want to point out that your response contradicts itself a bit. You said that you covered loss (miscarriage, stillbirth) but also that TFMR was excluded, partially on the basis that there are a variety of conditions/circumstances that might merit a TFMR. Well, that’s true about the causes behind miscarriage and stillbirth. So why were we left out? I have done some research on my own to try and quantify just how many of us have experienced TFMR in the US. It’s likely at least 10% of all abortions in the US, probably higher. I arrived at this number a few different ways (looking at percent of 2nd and 3rd trimester abortions), plus looking at percent of live births compared to percent of major fetal congenital diagnosis (3-4%) with an average termination rate of about 80%. Stillbirth affects about 21,000 pregnancies in the US every year. TFMR is potentially as high as 80,000-90,000, and yet we are expected not to talk about it in explicit terms (as abortion) even though our access is becoming increasingly limited. I have read absolute horror stories from TFMR parents who could not get care in their states and had to travel for clinic abortions in the second or third trimester.
I do hope moving forward, that you will acknowledge TFMR as a rather common and still extremely stigmatized pregnancy outcome. When I had mine, I found out that my aunt, my therapist’s sister, and my best friends sister-in-law, had all had TFMRs. No one ever talks about it and I was shocked to learn that my own aunt went through this.
I know you have a huge platform and the impossible task of covering everything and pleasing everyone. I also hope you will devote more attention to this topic in future publications.
Finally, for anyone who would like to read some research on TFMR, social support, and mental health outcomes I can recommend this article – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10240332/

emu147@hotmail.com
emu147@hotmail.com
21 days ago
Reply to  Liz
21 days ago

👏🏼👏🏼👏🏼

Danamac13
Danamac13
24 days ago

Erica,
I haven’t read the book, but when I saw TFMR was likely not covered based on Emily showing the table of contents on Instagram, I felt the same way. TFMR is so isolating and definitely not treated in the same way as other complications. I’m in the same boat and I’m sorry. It’s a super crappy boat to be in. -Dana

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Comment “Link” for a DM to an article on the data around sun and heat exposure for babies.

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☀️ If you want to add a little sunscreen on their hands and feet? Go for it! But be mindful as baby skin tends to more prone to irritation.

Comment “Link” for a DM to an article on the data around sun and heat exposure for babies.

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