In the first national survey of U.S. obstetricians' attitudes towards counseling pregnant patients about environmental health hazards, nearly 80 percent agreed that physicians have a role to play in helping patients reduce their exposures, but only a small minority use their limited time with patients to discuss how they might avoid exposure to toxics, according to a UCSF-led study.
Only one in five of the 2,500 physicians surveyed said they routinely asked about these exposures, and just one in 15 said they had received training on the harmful reproductive effects of toxic chemicals that are ubiquitous in the bodies of pregnant women in the United States.
The doctors surveyed said they didn't know enough or were too uncertain of the evidence to feel comfortable making firm recommendations to pregnant women. They also said their patients often have more pressing and immediate health concerns, such as poor diet, sedentary lifestyles, obesity and chronic medical conditions like diabetes. In focus groups, physicians said they were afraid of scaring their patients about the chemicals found in the workplace and in thousands of household and industrial products, since it's almost impossible to avoid being exposed to them.
While acknowledging that the problem can seem overwhelming, the authors said there are still things that doctors can do to help patients, even those who may have little control over their living and working environments and cannot afford luxuries like organic food.
"Many environmental exposures are unavoidable," said Naomi Stotland, MD, an associate professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at UCSF, a physician at one of UCSF's partner hospitals, San Francisco General Hospital and Trauma Center, and the study's lead author. "So, we counsel women on the substances that we know are most likely to cause harm, while providing them with practical ways of reducing their exposures."
The authors said that if physicians had better training and evidence-based guidelines, they could be more proactive, without fear of unduly alarming their patients. Previous studies have shown that women want to know about the adverse effects of the chemicals they're exposed to and that they can react productively to this information.
"We have good scientific evidence demonstrating that pregnant women are exposed to toxic chemicals, and there's a link between these exposures and adverse health outcomes in children," said Tracey Woodruff, PhD, MPH, who directs the UCSF Program on Reproductive Health and the Environment at UCSF and is the study's senior author. "But physicians are not offering this information to their patients."
Last year, the two leading women's health professional societies, the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM), issued a Committee Opinion on Exposure to Toxic Environmental Agents, in recognition of the dangers that chemical exposures pose to women's health.
But while drug companies must perform rigorous tests of their products before marketing them to the public, chemical makers face no such constraints, and few of the toxic chemicals in widespread use have been tested for their effects on pregnant women and children.
"The remedy goes beyond improving physician knowledge and patient counseling about environmental chemicals," said Jeanne Conry, MD, PhD, of Kaiser Permanente, who is the immediate past president of ACOG and also a co-author of the study. "We don't know where the most harmful chemicals are used, how we are exposed to them or what the health risks from these exposures might be. We need to leverage the voice of health professionals in policy arenas, as well, to shift the burden of proof about a chemical's safety or toxicity to the manufacturers."
- Naomi E. Stotland, Patrice Sutton, Jessica Trowbridge, Dylan S. Atchley, Jeanne Conry, Leonardo Trasande, Barbara Gerbert, Annemarie Charlesworth, Tracey J. Woodruff. Counseling Patients on Preventing Prenatal Environmental Exposures - A Mixed-Methods Study of Obstetricians. PLoS ONE, 2014; 9 (6): e98771 DOI: 10.1371/journal.pone.0098771
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