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Doctors lack tools to discuss toxic exposures with pregnant patients: survey

By Shereen Lehman

NEW YORK (Reuters Health) - Obstetricians recognize that exposure to chemicals and metals can affect a pregnancy, but said in a new survey that they face barriers to counseling patients about environmental hazards.

The first of its kind study found that U.S. obstetricians and gynecologists feel they lack the medical education and training, evidence-based guidelines and tools for communicating potential environmental risks to patients.

“The main barrier is something the doctors in our focus groups called ‘Pandora's Box’,” Dr. Naomi Stotland, who led the study, told Reuters Health in an email.

“They don't even want to approach this topic because they are afraid it will cause anxiety in pregnant patients and unleash a barrage of new questions and they won't have the answers to those questions,” said Stotland, an obstetrician and researcher at the University of California, San Francisco School of Medicine.

Stotland added that another key obstacle is lack of training and education about prenatal environmental exposures and how to counsel women.

“Most medical school and OBGYN residency curricula don't currently cover this topic,” she said.

Providers who care for lower-income women feel that they have limited time and more pressing issues to cover, such as poor diet, poverty and psycho-social stressors, so they don't feel they can engage their patients in discussing this topic, Stotland added.

“In contrast, the providers who care for higher-income and higher-educated women said that they were frequently fielding questions from their patients about exposures; for example, one doctor said her patient pulled out her cosmetic bag and wanted the doctor to see every ingredient and tell her if it was safe to use during pregnancy,” she said. “The provider did not feel prepared for this so referred her to various websites.”

Stotland said she works with mainly low-income immigrant patients and they essentially never ask her about environmental exposures.

“So we found this contrast by patient demographic, which we thought was especially interesting given that lower-income populations actually tend to have higher exposures to harmful chemicals,” she said.

To learn how OB/GYNs across the country handle the issue of environmental exposures, Stotland and her colleagues developed a 64-question survey, which they sent to fellows of the American Congress of Obstetrics and Gynecologists in the fall of 2011. A total of 2,514 obstetricians responded.

The survey included questions about the physicians’ knowledge of the impact of prenatal environmental exposures and how often the doctors spoke to patients about their environments, including about 19 specific substances.

In addition, doctors were asked if they had training in environmental health, if they had trusted sources of information about it and what types of environmental choices they made in their own households.

The researchers found that 78% of obstetricians agreed they could reduce patient environmental exposures by talking to them about the topic.

But 50% reported that they rarely take an environmental health history from patients and only 1 in 15 reported having had any training on the topic.

Less than 20% of the obstetricians said they regularly ask patients about common chemicals, such as phthalates, BPA, pesticides and PCBs, according to the results published online June 25 in the journal PLOS ONE.

The researchers also held three focus groups with 22 obstetricians and heard that the main barriers to counseling included being unfamiliar with the scientific evidence and uncertain about how solid it is. Also, doctors worried that patients may lack the ability to reduce or eliminate hazards in their environment and did not want to cause the pregnant women excessive anxiety.

“Doctors may not be ready to answer all of your questions - but definitely you should ask if you think you might be exposed to harmful chemicals in your workplace during pregnancy,” Stotland said.

She added that there are specialty units around the country called Pediatric Environmental Health Specialty Units - PEHSUs, which have expertise and anyone – patients or doctors - can call them (click here for a list: http://bit.ly/1lcSUPG).

“We also recommend that providers and women check out the brochure that UCSF researchers created called ‘Toxic Matters’ - it's available in English and Spanish and covers practical tips women and their families can use to reduce their exposures to common harmful chemicals,” Stotland said. (See http://bit.ly/1pjRLhL).

Dr. Ruth Etzel, a pediatrician with the University of Wisconsin, Milwaukee, said she was “thrilled” to see that obstetricians are addressing this issue.

“We've actually been trying to encourage pediatricians as well as other clinicians to consider the environment seriously but it's taken a lot of time to get people to take this up,” she said.

Etzel was founding editor of Pediatric Environmental Health, which serves as a training manual to help pediatricians learn how to recognize environmental hazards. She was not involved in the current study.

“To me this study shows that they’re surveying where they are, what the barriers and challenges will be and it's a fabulous place to be because it means they're ready to launch some programs to improve the way that obstetricians counsel women about environmental hazards, so I think it's really a wonderful step,” she said.

One of the most important things pregnant women can do is ask about the chemicals that they have in their homes or where they work, such as cleaners, cosmetics, cookware, home remedies and well water, among other things, Etzel added.

“By asking about the chemicals, they awaken the obstetrician to the issue, and the obstetrician then is going to go look it up and find out more about it and so it's one way for the consumer to change physician behavior,” she said.

SOURCE: http://bit.ly/1qJk9Jq

PLOS ONE 2014.

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