Pregnant Women’s perceptions of exposure to brominated flame retardants

Increased media attention has reflected the research suggesting exposure to brominated flame retardants (BFRs) may be associated with harmful health effects in pregnancy. However, to date there has been no action taken by clinicians, professional organizations or governments to inform pregnant women of the widespread use and potentially harmful health effects of BFR exposure and the potential to reduce exposure. Our research was undertaken to explore the perceptions of pregnant women regarding BFR exposure in pregnancy. With Research Ethics Board approval, pregnant women from Southwestern Ontario Canada were recruited through the use of posters and pamphlets in prenatal clinics, prenatal fairs and community centres. The interviews were audiotaped and transcribed word for word. The transcripts of the interviews were analyzed using a rigorous research method called “qualitative analysis” including NVIVO 10™ software. After 22 pregnant women had been interviewed and their transcripts analyzed, it was felt no new information was being offered, and thus no additional pregnant women were recruited. Four themes were co-constructed: I-Lack of Awareness of BFRs, II-Factors Influencing BFR Exposure, III-Responsibility and IV-Informed Choice. Many participants felt that flame retardants were difficult to avoid through individual means. In the future, they wanted better communication from their clinicians and governments, and regulations that would promote decreased exposure. Pregnant women in Canada may be unaware of the potential risks of exposure to BFRs. Professional organizations and governments should further study risk associated with BFR exposure in pregnancy and provide educational materials for pregnant women and clinicians regarding BFR exposure.

Brominated flame retardants (BFRs) are added to household products such as furniture and textiles to decrease their flammability [1]. BFRs are released into the air as dust and are subsequently inhaled or consumed with food [2]. Contact with contaminated dust accounts for approximately 82% of human exposure [2]. BFRs cross the placenta [3] and their levels in human umbilical cord serum have been shown to be significantly higher than levels in maternal serum [4]. In addition, BFRs are found in breast milk [5]. These data suggest that the fetus and postnatal infant may be highly exposed to BFRs via their maternal environment.

Women are exposed to many endocrine disrupting chemicals at a low level [6, 7], including BFRs, throughout their life and during pregnancy. These exposures could potentially act additively or have a synergistic effect [8]. However, there remains considerable uncertainty about the risks of exposure to these complex chemical mixtures since scientific methods to adequately assess risk have not yet been developed [8].

Prenatal BFR exposure in humans has been associated with signs of endocrine disruption, including abnormal male genitourinary development (cryptorchidism) [9], hernia and hydrocele [10], and alterations in the thyroid hormone axis as well as male hormone levels [11, 12]. Animal studies also report that exposure to BFRs is associated with several indices of endocrine disruption [13, 14], including androgen signaling and thyroid changes [15], in addition to hepatotoxicity [16, 17] and abnormal neurobehavior [18].

Numerous studies have shown that some of the highest concentrations of flame retardants within our everyday environment occur in North America [19]. Biomonitoring studies in the United States and Canada indicate a ten to one-hundred fold higher serum levels of BFRs compared to populations in many other regions of the world [19]. Increased media attention on these BFR studies may be raising anxieties in North American pregnant women and women planning to become pregnant [8].

As clinicians providing obstetrical and preconceptual care may not be generally informed about BFRs except through the same media attention their patients may receive, the responsibility falls on professional organizations interested in reproductive health to provide comprehensive and accessible resources for clinicians as well as for pregnant women. In the United Kingdom, the Royal College of Obstetricians and Gynaecologists published a scientific impact paper entitled “Chemical Exposures During Pregnancy: Dealing with Potential, but Unproven, Risks to Child Health” to raise awareness of the current issues surrounding chemical exposure by issuing a list of products which pregnant women and women contemplating pregnancy should avoid to minimize harm to their pregnancy [8]. In addition, professional development tools such as “Environmental Impacts on Reproductive Health” by The Association of Reproductive Health Professionals (ARHP) [20] and an editorial entitled “Potential Toxicity of Synthetic Chemicals: What You Should Know About Endocrine-Disrupting Chemicals” in the American Family Physician are resources for clinicians [21]. The American Congress of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM) in 2013 showed concern about endocrine disrupters, and have urged the Environmental Protection Agency (EPA) to take measures “to ensure the safety of all mothers and infants from toxic environmental agents [22]. However, neither ACOG nor ASRM provide specific guidance to clinicians as to how to discuss avoidance of endocrine disruptors in general or BFRs in particular.

There has been no action taken by Canadian clinicians, professional organizations or governments to inform pregnant women and women planning pregnancy of the widespread use and potentially harmful health effects of BFR exposure and the potential to reduce exposure. The purpose of this study was to explore pregnant women’s perceptions of exposure to BFRs and their views on the role of clinicians as well as the government in providing appropriate information about BFRs.

The results of the analysis have been organized under the four themes encompassing the concepts identified in the earlier phases of coding and reflect distinct issues and concerns: Theme I–Lack of Awareness of BFRs; Theme II–Factors Influencing BFR Exposure; Theme III–Responsibility; and Theme IV–Informed Choice. Figure 1 presents an overview of how the research participants’ comments were organized into the various categories and were then grouped into various subthemes and then further organized into these overarching themes. Sample excerpts from the transcripts illustrating each of the four themes are presented in Tables 1, 2, 3 and 4.

In this study, pregnant women consistently believed that there is a responsibility of clinicians and governments to inform women about BFR exposure in pregnancy and strategies for avoidance, as long as Canadians continue to be exposed to BFRs. Increasing awareness of the potential harms of flame retardant exposure in pregnancy allows the individual woman to be aware of exposure to BFRs and to make informed decisions to reduce exposure to BFRs if possible [8]. However, lack of information sources on routes of exposure and potential harms of flame retardants in consumer products makes it difficult for pregnant women and women contemplating pregnancy to make such informed choices regarding how and to what extent they may decrease their exposure to flame retardants [26, 27].

Investigative media reporting may bring awareness of the risks of BFR exposure in pregnancy to these women, but is not a sufficient information source for informed choice [27].

Further study is needed to determine the risk associated with BFR exposure during pregnancy. At the current time, scientific methods to adequately assess risk of exposure to BFRs has not been developed [8]. A significant limitation in developing adequate methodologies has been the ubiquitous nature of BFRs preventing comparison between exposed and unexposed groups given that no unexposed groups exist. As such, future methods may benefit from dose response analysis to determine if there is a threshold exposure limit.

As Canadian clinical practice guidelines on BFRs do not currently exist, it is difficult for clinicians caring for pregnant women and women planning pregnancy to discuss flame retardant exposure. Without the possibility of such discussion with clinicians and lack of reliable public information strategies, such as by Health Canada, informed choice regarding avoidance of BFRs does not exist. Regulations can play an important role in shaping what is viewed as healthy behaviors during pregnancy and the “health of the embryo” [28], however, regulations on the use of BFRs and the impact of BFR-containing products do not currently inform Canadians of household exposure [29]. Furthermore, even if stringent regulations were indeed implemented, individuals will likely continue to be exposed by previously manufactured products treated with BFRs, which could remain in daily use for decades [30, 31].

Zota et al [32] found that significantly higher levels of flame retardants have been measured in individuals of low socio-economic status. This problem is likely due to non-toxic alternatives being generally more expensive than mainstream brands and requiring available time to shop for chemical-free products. Consequently, mothers with higher incomes may be able to shop their way around BFR exposure, while mothers with low incomes may have a limited capacity to carry out the safest choices [26]. Additionally, low income families may be more likely to have old furniture with exposed foam. In order to provide universal protection for the public, it is necessary for precaution to be enacted at the regulatory level, rather than at the level of the individual consumer [26, 27].

As pregnant women in the United States and Canada are exposed to much higher concentrations of BFRs than many other countries in the world [19], we encourage the American Congress of Obstetricians and Gynecologists, the Society of Obstetricians and Gynaecologists of Canada, and other national organizations of physicians and midwives, and governments to further study risk associated with BFR exposure in pregnancy, as well as implement public education strategies to raise awareness and provide potential avoidance strategies for BFR exposure during pregnancy, and to provide educational materials for clinicians to discuss BFR exposure with their patients.

The research participants consistently felt that as long as women continue to be exposed to BFRs there is a responsibility of clinicians and governments to inform pregnant women and women contemplating pregnancy about exposure to BFRs and strategies for avoidance. The American Congress of Obstetricians and Gynecologists, other national organizations of physicians and midwives, and governments should further study risk associated with BFR exposure in pregnancy, as well as provide public education strategies to raise awareness and provide potential avoidance strategies, and educational materials for clinicians to discuss flame retardant exposure with their patients.