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
“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
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
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
The researchers found that 78% of obstetricians agreed they could
reduce patient environmental exposures by talking to them about the
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.
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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
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
“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.
PLOS ONE 2014.
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