The Pregnancy Risk Most Doctors Aren't Comfortable Talking About

When a woman is pregnant, she often takes immediate steps to cut out alcohol, steer clear of cigarette smoke, and avoid risky foods like sushi. But there are other potentially dangerous substances she interacts with every day at home or at work—things that aren’t so easily identified or avoided.

Analyses of the blood and urine of pregnant women regularly finds chemicals, like those in plastics, cleaning supplies, food cans, and other products. A 2011 study, for example, found that they were exposed to an average of about 40 environmental chemicals, including some that are linked to health problems, like phthalates (which are found in plastics) and compounds used as flame retardants.

Pregnant women aren’t necessarily exposed to more or worse chemicals or pollutants than non-pregnant people or people of other genders, but substances affecting a pregnant woman can also affect their still-developing fetus—which is far more vulnerable than the mother to any substances she comes in contact with.

Professional organizations like the American College of Obstetricians and Gynecologists (ACOG) recommend that OB/GYNs tell pregnant patients to take precautions against those sorts of risks. However, according to a study conducted by researchers at the University of Colorado, the vast majority of OB/GYNs aren’t talking to expectant moms about environmental pollutants or toxins, despite the recommendations to do so.

“This was something that we needed to show in order to bring more recognition to the issue,” says Natalia Grindler, a reproductive endocrinologist at the University of Colorado and the lead author on the study, which was titled as a call to action for the community. The results were published in the journal PLOS One in May.

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According to the study, 60 percent of surveyed doctors working with pregnant women said they aren’t screening patients for environmental risk factors. Specifically, while most physicians said they’re already speaking to their patients about health risks like alcohol and cigarettes, they aren’t asking about their patients’ dietary habits, lead or mercury exposure, or the chemicals they might use in their jobs. Far fewer—10 percent or less—ask about air pollution, personal care products, household cleaners, or using plastic for food storage.

Eight-five percent of the docs said they’re not comfortable screening for environmental factors. Only 10 percent said they know how to instruct their patients on the best way to reduce their chemical exposure. More than 300 OB/GYNs responded to the study’s online survey, which was circulated through the Department of OB/GYN at the University of Colorado and posted in social media groups for physicians trained in the field.

The research serves as a check-in on the impact of a 2013 opinion from ACOG’s Committee on Health Care for Underserved Women, which cited existing evidence on the danger some toxic environmental agents, like pesticides, could pose to a developing fetus, and called for providers to help limit the harms to patients.

“This new study shows that we’ve moved the needle a little, but we still have a lot to do,” says Linda Giudice, professor at the University of California at San Francisco (UCSF) and chair of the working group on reproductive and developmental environmental health at the International Federation of Gynecology and Obstetrics. “I’m not surprised by the results. I’m encouraged that they did the survey, though, and I’m encouraged that they framed it as a call to action.”

Doctors should be talking regularly with patients about those exposures, Giudice says. They should bring up things like bisphenol A, which can seep out of plastic water bottles and is tied to adverse pregnancy outcomes, like premature births and miscarriage, as well as cosmetics and fragrances, which often contain endocrine-disrupting phthalates, she says.

“It’s also important to have an action plan with what patients can do,” she tells me. “Don’t leave your plastic water bottle in the sun all day and then drink it, and wash fruits and vegetables, or buy organic.”

However, those conversations can be a double-edged sword. “It’s important that we don’t put any burden of guilt on pregnant women,” Giudice says. “We don’t want people to feel like they have to live in a bubble.” Women already have a laundry list of things to avoid during pregnancy, like deli meat, certain cheeses, and excessive caffeine—and often have their choices scrutinized by family and strangers.

The conversation around environmental risks also looks different for different patients, says Nate DeNicola, an assistant professor of obstetrics and gynecology at the George Washington University School of Medicine and Health Sciences, who worked on the 2013 ACOG committee opinion. Switching to all organic foods isn’t possible for many people, and quitting or modifying a job just because it involves working with chemicals often may not be an option.

It’s not a coincidence, he says, that the ACOG opinion came from the Committee on Health Care for Underserved Women. “Underserved and low-income pregnant women are disproportionately affected by toxic exposures,” he tells me. Doctors, therefore, should tailor conversations around environmental exposures to the situations of each patient. “Say, if organic food isn’t feasible, then maybe try to get groceries instead of fast food,” he says.

Still, some environmental risk factors are nearly impossible to avoid. Take air pollution, for example. It poses a host of risks to maternal and fetal health, but pregnant women can’t be expected to move because they live in an area with more polluted air, DeNicola says. And people with lower incomes, who might not have the resources to buy organic produce or modify their job to avoid chemical exposures, face a double whammy as low-income areas have higher concentrations of air pollutants to begin with.

But above all, the responsibility shouldn't be on the individual here, Giudice says doctors have to advocate for policy change to help pregnant women limit exposures. “Changing air pollution isn’t going to happen on an individual level,” she says. “You can minimize driving in peak rush hour, if you can, or not go in tunnels, but that can be a hard thing to do. What needs to happen is getting policy change around the things emitted from industrial plants.”

For the more easily modifiable behaviors, though, Giudice says professional organizations should develop practical information to give to doctors. “Having a succinct, easy-to-read, basic toolkit would go far,” she says. Putting that information together is already an immediate goal for some groups, like the Environment and Reproduction Special Interest Group at the American Society for Reproductive Medicine, she says. ACOG’s 2013 opinion already includes a list of key chemicals, and links to “exposure assessment” forms that instruct doctors to ask about everything from lead paint to chemicals used at work to personal care products.

Grindler is optimistic that, the more this topic is discussed, more physicians will have these conversations in daily practice. “OB/GYNs have a really strong dedication to their patients, and they’re willing to learn new things,” she says. When doctors have that kind of information, they’re more likely to pass it along to patients and discuss preventive strategies, she says. That’s key for improving maternal health, and the short- and long-term health of their child.

“It’s a different health consideration when it effects the next generation,” DeNicola says. “That’s a pretty awesome responsibility that OB/GYNs feel. Anything that puts that next generation at risk is something that deserves attention.”

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