Exposure of reproductive-age women to environmental toxins is an issue of national leadership and commitment. As an initial step, better management of information, including information vehicles, is needed. While perhaps not satisfying all constituencies, the current efforts of federal agencies and national nonprofit groups focused on environmental and occupational toxic exposures are noteworthy. Environmental science is slowly coming to the attention of public and private sector professionals concerned with MCH, but there is room for improvement. Organizational, as well as communication and behavior change aspects will clearly be important components, but effectiveness in these arenas remains uncertain with respect to a wide range of interventions.
While prenatal influences are important to consider, the earliest time periods—the periods prior to conception (preconceptional), not just prior to birth (prenatal)—demand greater attention. First, exposure during the preconceptional period may persist in body tissues (e.g., lead). Second, exposures in early life could permanently affect reproductive tract structures (e.g., diethylbestrol). Third, women may be unaware of pregnancy during the early period, when the fetus is most vulnerable to malformations and loss. Furthermore, this knowledge is likely influenced by demographic and psychosocial risk factors, so that women with the highest risk are the least likely to learn of their pregnancy early. Finally, even if women know they are pregnant, they may not be able to initiate prenatal care during this early period and receive information, as clinicians may not see women until 10–12 weeks gestation.
Therefore, we suggest adoption of a life course approach to this problem, which should lead to an expansion of education efforts and presumably not to a dilution of the message. For example, risk communication efforts need to target providers beyond obstetricians/gynecologists and midwives. Ways to reach nonpregnant women with these messages need to be developed. We must ensure that a one-size-fits-all strategy does not evolve as a result of shifting to a life course approach.
To date, more focus (and action) has been given to child health, with a concomitant lack of attention and resources given to environmental toxicant exposures during the preconceptional and pregnancy periods. Even if the goal remained to improve children's health, it is clear that exposures to children's mothers (and fathers) prenatally and even prior to conception may have a lifelong impact on the child. To truly protect children from environmental toxicants, we need to expand beyond a narrow conceptualization of children's EH and consider exposures during these earliest time periods. The recent investment in the National Children's Study affirms the interest of researchers and policy makers in investigating the potential lifelong effects of prenatal exposures on childhood and adult health.
Another foundational area is in the field of risk communication. Risk perception plays a central role in risk communication strategies. Bennett compiled a list of “fright factors” that may lead to perception of risks as “more worrying and less acceptable.” Nearly all of these factors apply to the issue of environmental toxicants and reproductive/perinatal health, suggesting that risks might be perceived as more alarming for this topic than for others. What little is known specifically about risk perception by women regarding pregnancy suggests that there are factors resulting in overestimation of risk.61–64
The findings of these studies highlight the very charged context of pregnancy with regard to risk communication, a factor we must consider as we seek to inform women of risks of exposures that may be difficult to prevent. It is clear that we are far from a complete understanding of how women perceive risk during pregnancy—an important domain to master to develop effective risk communication about potential hazards, such as environmental toxicants.
Our review of environmental risk communication in relation to perinatal outcomes suggests, then, a number of potential next steps for concerned professionals and government agencies. We believe that there are several straightforward and low-cost actions that can be taken in the short term. In addition, our analysis points to both a need and an opportunity to reduce environmental hazard exposures preconceptionally and in the pregnancy period over the longer term.
Feasible short-term actions
Capitalize on public notification requirements that stem from environmental legislation.
Government agencies can work together and with their nonprofit partners to further enhance their websites and print materials by organizing available information. Technological tools, such as links to local environmental data on existing websites, could serve as a model and means for making perinatal health-related information more accessible to women and health-care providers. This would further require some translation of the scientific data and related information for general public audiences, as well as efforts to address culture and language-specific targeting concerns.
Continue and enhance use of the news media.
As noted, mass media can be influential and already has demonstrated an interest and commitment to report on environmental issues. Partnerships exist in other arenas of health care wherein journalists convene for education on selected topics (e.g., Journalism Fellowships in Child and Family Policy and the Knight Center for Specialized Journalism) so that the information they provide is clear, accurate, and systematically presented (e.g., foundation-supported projects that focus on health-care reform and expansions of publicly supported health insurance for low-income children). A parallel effort could be undertaken to focus on EH exposure risks to women and children.
For some toxicants, product labeling has tremendous potential to change exposure; however, the knowledge base in this area is minimal (). To explore how labeling can be effectively implemented in this arena will likely require a systematic set of research and demonstration projects.
Reexamine potential workplace interventions.
An opportunity also exists for exploring with labor unions, the Occupational Safety and Health Administration, and occupational health professionals how improvements might be made in relation to reproductive and perinatal health concerns in the workplace systems of toxic risk notification and safety education. In addition, such efforts could serve as a vehicle for promoting initiatives to further reduce or eliminate environmental tobacco smoke in the workplace.
Promote improved health-care provider counseling for women and couples.
Given the greater likelihood of exposure in impoverished and/or isolated geographic communities, the EH professional community might consider establishing and/or strengthening partnerships with the Health Resources and Services Administration to implement targeted and vigorous outreach to health-care providers working in area health education centers, community health centers (including those for migrant workers), and MCH programs in states and communities. These education and service programs address the needs of the most vulnerable groups (e.g., low-income, minority, immigrant, and geographically isolated populations). They also have strong relationships with provider organizations and training programs, such as the National Health Service Corps, which interface with medical professionals serving such groups.
To make up-to-date information on relevant environmental science more accessible to women's health providers, the organizations' online strategies could be replicated in the MCH professional community. American College of Obstetricians and Gynecologists, other MCH professional organizations (e.g., American College of Nurse-Midwives, Association of Women's Health, Obstetric and Neonatal Nurses, American Academy of Pediatrics, and American Academy of Family Practice), and MCH-related government agencies (e.g., Maternal and Child Health Bureau, and the Office of Women's Health, Centers for Disease Control and Prevention [CDC] Divisions of Perinatal Health and Birth Defects) can feature information on EH hazards more expansively and prominently in their communications, including websites.
Efforts also might be made to capitalize on CDC's preconception health and health-care initiative and advocate for greater attention to EH concerns. While this initiative has acknowledged these issues, to date relatively few EH professionals or agencies have gotten involved in the initiative, and the issue of hazardous environmental exposures (acute and/or chronic) has not been a high priority.
McDiarmid and Gehle recommend that the environmental history be expanded to (1
) include assessment of environmental exposures that occur in a woman's home, community, or workplace and (2
) present an occupational/environmental history checklist, adapted from work by Grajewski,65
for use by providers at the preconception visit.56
Faucher echoes this notion.66
Information technology tools developed initially in the pharmacy industry to assist medical care providers in examining and calculating risk in relation to contraindications in medication might be designed to assist in calculating environmental exposure risks, thereby enhancing capabilities in counseling women and their partners.
Tailoring of risk messages has moved to the forefront in other areas of risk communication, with a number of investigations indicating that tailoring improves communication.67,68
Tailoring was initially applied to print communications,68
but has been used more recently in online materials, where information is gathered from the individual and used to create tailored messages dynamically.69
Information about a woman's residential and occupational environments could be ascertained and combined with various databases to create a uniquely tailored risk assessment and risk communication message.
While systematic surveillance is available for many reproductive and perinatal outcomes, routine monitoring of spontaneous and induced abortions as well as infertility faces limitations due to data availability and quality. Birth defect registry data are available but are not routinely monitored with regard to potential environmental impact, nor are the levels of toxicants monitored in correlation with birth defects or other reproductive and perinatal outcomes.
The limitations of national and local data impede our ability to track environmental impact over time. Further, as we seek to implement population-based interventions to reduce maternal exposures, impact on reproductive and perinatal health outcomes will be difficult to ascertain without increased surveillance of outcome indicators. In some cases (e.g., spontaneous abortions), data collection will need to expand. Other outcomes (e.g., birth defects) may only require increased use and monitoring of existing data.
Increased measurement and monitoring of both toxicant biomarkers (e.g., blood levels) and self-reported exposures for pregnant women and women of childbearing age is needed. This might be accomplished by additions to existing national surveys and examinations, including the Pregnancy and Risk Assessment Monitoring System, the Behavioral Risk Factor Surveillance System, the National Survey of Family Growth, the National Survey of Children's Health, and the National Health and Nutrition Examination Survey. Federal agencies could also collaborate with OTIS and pediatric environmental health specialty units (PEHSUs) to systematically track data on knowledge and actions of pregnant women.
Create an organized system of information and care specific to hazardous environmental exposures related to perinatal health.
Consideration should be given to creating a more organized approach to information compilation, dissemination, expert technical advice, and guidance for medical education that is similar to the system used by U.S. poison control centers (PCCs). In its recent review of PCCs nationwide, the Institute of Medicine noted that while there are aspects of the PCC system that need to be strengthened, they represent a critical set of services.70
Resources that might be used and enhanced to replicate this model in the arena of perinatal environmental risk exist, but potential impact is hampered by (1
) limited geographic coverage of the Toxicology Information System (TIS), (2
) absent or weak linkages between the PEHSUs and TIS, and (3
) absent or weak connections with MCH programs and with the Center for the Evaluation of Risks to Human Reproduction health research. To be effective, such a system needs to be very publicly visible (to assure universal access for the population and for professionals) and should be a joint private and public health/MCH and EH science effort. Consideration might be given to ways in which OTIS and the PEHSU collaboration could play a role in design and implementation.
Undertake a nationally visible and scientifically and politically credible initiative that brings together health and environment, with a focus on preconceptional and prenatal toxic environmental exposures.
The current state of governmental complexity and fragmentation with respect to research, public information, regulation, and health services likely thwarts the natural evolution of collaborative action in this arena. The EPA's Prenatal Partnership on Environmental Health has made some progress in this regard, but certain key players have not been present at the table; most notably, the Health Resources and Services Administration (both the MCH Bureau and the Bureau of Primary Care) and public sector professionals with a major focus on MCH. Moreover, community and state government agency representatives should be key participants.
A report by the U.S. Surgeon General or the Institute of Medicine may provide unifying structure and public policy visibility. Deliberation undertaken to develop such a report would need to include a discussion of the role federal, state, and local agencies in MCH and EH play with regard to protecting pregnant women from environmentally hazardous exposures. This initiative would work toward:
- National shared goals;
- A rational organization of complementary program components for knowledge development (research), information dissemination, consultation, and service, as well as research that includes community-state-national linkages;
- A prevention model that incorporates a lifespan perspective through primary (information and education), secondary (risk identification), and tertiary (counseling) prevention services that would serve as the underpinning; and
- Communication mechanisms that link all components and strengthen accountability (including use of data/surveillance and other feedback systems) for improved outcomes for women and children consistent with the shared goals articulated.