Advising Parents in the Face of Scientific Uncertainty: An Environmental Health Dilemma

Abstract

Naomi Stotland and her colleagues have been trained to tell their obstetric patients not to blame themselves for a miscarriage; fetal genetic abnormalities and other uncontrollable factors are generally the cause.1 But after listening to one of her residents counsel a patient who had just had a miscarriage, “I asked myself if we were leaving out part of the story,” Stotland wrote in a recent blog post.2 For Stotland, a researcher with the Program on Reproductive Health and the Environment (PRHE) at the University of California, San Francisco (UCSF), the story includes where patients live and work—for instance, if they have jobs where they must use solvents, say, as a housecleaner or working at a dry cleaners or in a nail salon. Environmental health research links occupational solvent exposures to adverse health outcomes including miscarriage and birth defects,3,4 but doctors may not ask their patients whether they encounter these chemicals, instead focusing on warning them about alcohol and drug use or asking if they smoke, Stotland wrote.2 Although population-level effects have been documented for many pollutants, direct connections between environmental exposures to chemicals and individual health outcomes can be hard to make, for both clinicians and laypeople. These seemingly spectral threats may be the least of some parents’ worries, and for that matter, their doctors’ as well. For other parents, these issues are a source of great concern, even though the potential health effects involved for individuals are far from certain. Jeanne Conry, chairwoman of the American Congress of Obstetricians and Gynecologists for California, says some doctors face enough challenges in managing well-known problems such as the rise in diabetes and obesity in expectant mothers.5 “The risk of birth defects if [a pregnant woman’s] blood sugar gets out of control is significant, several times higher than somebody who has normal blood sugars,” she says. “The research has been out there for years, and we’ve been trying to get women to understand that kind of thing . . . [but] we haven’t accomplished that.” With such established worries, she surmises, less well-defined environmental threats may be considered secondary risks by most practicing doctors. It takes time to get the message out. You have to do this in a multipronged approach. —Jeanne Conry, American Congress of Obstetricians and Gynecologists for California But the many uncertainties around specific environmental health hazards should not be confused with the strength of the evidence, says Patrice Sutton, a research scientist at PRHE. She and her PRHE colleagues therefore seek to provide evidence-based information in a responsible manner to doctors and other clinical practitioners who serve as a frontline for pregnant women and other patients concerned about exposure to environmental chemicals. Their ultimate target is the larger community and the legislators and policymakers who could regulate chemical exposures. “Our approach is to communicate the science clearly so that individuals have the information they need to apply their values and preferences,” Sutton says. But communicating about environmental exposures implies more than changing individual behaviors, she adds: “Because many exposures are not avoidable by individuals, it means harnessing knowledge to improved policy to prevent the introduction of hazardous exposures into homes, communities, and workplaces.”