Can exposure to chemical products be reduced during pregnancy?

Abstract

Background

Exposure to chemical products during pregnancy is a growing threat to maternal and fetal health.

Objective

The aim of this study is to investigate the effectiveness of Motivational Interviewing (MI) based education in reducing the use of products that may contain chemicals among pregnant women and in creating a change in attitudes towards the use of these chemicals.

Methods

The study was conducted using a pretest–posttest randomized controlled design with 130 pregnant women. Intervention group received three face-to-face MI based education sessions aimed at reducing the use of products that may contain chemicals. Participants reported using frequencies of personal care and domestic products that may contain chemicals. Attitudes toward avoiding potentially harmful chemicals were additionally measured using an Endocrine Disrupting Attitude Scale (EDAS).

Results

A statistically significant difference was found when comparing the differences (pre-test-post-test) in personal care and domestic products that contain chemicals usage between the experimental and control groups p < 0.05. In the experimental group, a decrease in the use of most products was observed in the post-test. While the pretest EDAS mean scores of the pregnant women in the intervention and control groups were similar, the posttest EDAS mean scores increased. Results indicated a significant main effect in traction between group and time for EDAS (F13.06; η2 = .093, P < .001).

Conclusion

MI based education was an effective method to reduce the use of products that may chemicals and develop positive attitude towards protection against use of products.

Trial registration

The study was registered retrospectively with the Clinical Trials Protocol Registration and Results System. NCT06380634. (registered 24.04.2024).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-026-08987-5.

Introduction

Scientific evidence regarding the impact of environmental factors on health is steadily increasing, making changes in these factors even more crucial. Exposure to various chemicals, which are environmental factors, is a growing problem all over the world. It has been reported that continuous use of chemical products may lead to the cumulative accumulation of their constituent substances in the body, thereby increasing overall exposure and shortening the time required for toxic effects to occur [1]. Despite increased vulnerability during the perinatal period, studies suggest that many pregnant women maintain regular use of personal care and household products, indicating limited change in usage patterns [2, 3]. For example, it has been reported that only less than 20% of women restrict the use of cosmetic products during pregnancy [4–6]. In addition, studies show that more than half of women do not feel sufficiently informed about environmental exposure sources and seek support from healthcare professionals in this regard [4, 5, 7]. In recent years, despite increasing scientific evidence on the adverse outcomes of perinatal exposure to chemicals, social and clinical awareness remains limited [5]. In 2021, the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine published a joint statement on the maternal-child health threat of environmental chemicals [8]. The French National College of Midwives has developed a guide for professionals to reduce perinatal exposure. This guideline recommends reducing the frequency and amount of cosmetic use during the perinatal period, preferring simple, unscented and rinseable products with short ingredient lists, avoiding industrial wipes and using soap and water for cleaning [5]. Despite increasing interest in chemical exposures during the perinatal period, evidence regarding the prevalence and health effects of such exposures, as well as the effectiveness of interventions aimed at reducing harm, remains limited. While etiological studies examining prenatal exposure to specific chemical families such as endocrine-disrupting chemicals, phthalates, and bisphenols exist (including meta-analyses for some exposure-outcome relationships), the intervention literature addressing strategies to reduce exposure during pregnancy is relatively small. Furthermore, prenatal exposure to toxic chemicals has been studied from a broad and heterogeneous perspective. Current studies have examined a wide range of chemical sources, including cosmetics, personal care products, household products, and various classes of environmental chemicals. This heterogeneity in exposure definitions and product categories makes comparing findings between studies difficult. Most studies rely on the measurement of chemical biomarkers in blood or urine during pregnancy, or on self-reported data regarding products [3, 9]. Intervention studies aimed at reducing product use have primarily focused on two main domains: dietary modifications and behavioral changes. Dietary interventions commonly involve changes related to water consumption, the use of plastic food containers, consumption of canned foods, and preference for organic products, whereas behavioral interventions target everyday practices associated with product use [10]. Both dietary and behavioral interventions vary in their implementation strategies; some consist of educational programs delivered over multiple sessions, while others are based on restricting the use of specific products in accordance with the study objectives. However, across both approaches, the sustainability of intervention effects remains a significant challenge [11]. Many of these interventions rely primarily on short-term, information-based educational sessions and do not adequately address participants’ motivation. Motivational interviewing (MI), which is a method that aims to increase the motivation of the individual in maintaining positive health behaviors and abandoning risky health behaviors, is a method with known effectiveness [12, 13]. MI is an approach, collaborative and client-centered method that encourages behavioral changes and increases the motivation of the individual. Motivational interviewing-based education has also been effectively used to create behavioral changes in pregnant women in a wide range of areas, such as tobacco use, gestational weight gain, and preferred delivery method [14–16].

The aim of this study was to investigate the effectiveness of MI based education in reducing personal care products and domestic products that may contain chemicals use in pregnant women and in developing a positive attitude towards protection against use of these products.

Methods

Study design

The study was conducted in a pretest-post-based randomized controlled design. The study was registered retrospectively with the Clinical Trials Protocol Registration and Results System. The trial protocol has been registered on 24.04.2024. Clinical Trial Registration: NCT06380634.

Sample selection

The sample of the study consisted of 140 pregnant women who applied to the Obstetrics and Gynecology Polyclinic of a State Hospital in Sile between May and December 2023, who volunteered to participate in the study and who met the inclusion criteria.

At the time of the study design, no prior experimental studies using comparable measurements and outcomes were identified in the literature that could provide a reliable estimate of effect size. Therefore, in line with common methodological practice, a medium effect size (Cohen’s d = 0.50) was assumed for the a priori power analysis conducted in G* Power (3.0.10) Program.

The sample size was determined as at least 64 people for each of the experimental and control groups with 80% power, 0.05 margins of error and 0.50 effect size. Afterwards, considering that data loss might occur (10%), 70 individuals were included in each group (total 140). The groups were randomized into 2 groups using a web-based randomization program (http://www.randomizer.org).

Participants

The inclusion criteria for the experimental and control groups were; being over 18 years of age, to have at least primary education, to be able to express oneself, to have a single pregnancy between the 8th and 40th weeks, to use personal care products and domestic products that may contain chemical (at least two personal care products and at least two household chemicals at least once a week). Exclusion criteria were having a psychiatric illness that would prevent communication, having a chronic serious physical health problem, termination of pregnancy for any reason, having a high-risk pregnancy (preeclampsia, threatened preterm birth), intrauterine growth retardation, having a pregnancy with fetal anomalies, having a job that requires intensive chemical use such as hairdresser, dry cleaner, beautician. The study period, 357 women were evaluated, 68 women did not meet the inclusion criteria, and 149 women did not consent to participate the study. The pretest of the study was started with 140 women. The posttest was completed with 130 women (69 women intervention group, 61 women control group). The CONSORT flowchart is shown in Fig. 1.

Fig. 1.

Consolidated standards of reporting trials flow diagram (http://www.consort-statement.org/) Abbreviation: MI; Motivational Interviewing

General hypothesis of the study

• H1: Motivational interviewing-based education ion is effective in reducing the use of personal care products and domestic products that may contain chemicals among pregnant women.

• H2: Motivational interviewing-based education is effective in maintaining a positive attitude towards protection against products that may contain chemicals among pregnant women.

Measures

The information form

The Information Form used in this study were developed in accordance with the academic literature.

This form included total of 21 demographic questions (age, education level, income level) and questions related to pregnancy (e.g. primiparous/multiparous).

The form for the use of personal care and domestic products that may contain chemicals

Since there was no valid and reliable tool for measurement, a new form was prepared by the researchers in line with the literature [3, 5, 17]. The form consisted of two sections: personal care products and domestic products that may contain chemicals.

The use of personal care products were asked with five categories and 26 product names. Skin products-rinse (soap, shower gel, make up remover, facial cleaner, facial mask, toothpaste) skin products-leave-in (body moisturizer, facial moisturizer, hand moisturizer, face care cream, sun screen, eye care cream, tonic, deodorant, perfume, nail polish and remover) hair products (shampoo, hair conditioner, hair color, hairspray/jelly/mouse) make-up products (foundation, blush, eye shadow, eye pencil, mascara, lipstick/gloss).

The uses of domestic products that may contain chemicals were asked with 8 product names (detergent, softener, bleach, descaler, floor cleaner, dishwashing detergent, scented candle, pet bottle) (Appendix 1).

Endocrine Disruptors Attitude Scale (EDAS)

The scale was developed by Miral et al., to determine the attitude of adults towards endocrine disruptors and consists of 21 items. There are two sub-dimensions of the endocrine disruptors attitude scale: consumer behavior and nutrition and hygiene. The high scores indicate that adults have a positive attitude towards protecting themselves from endocrine disruptors. Cronbach's Alpha reliability coefficients 0.85 [18]. In this study, their liability coefficient of the scale was found to be 0.82.

Data collection and procedure

Women who met the eligibility criteria were provided with information about the purpose and content of the study; those who agreed to participate were asked to sign the Informed Consent Form. All participants completed the Information Form, form of use of products use and the Endocrine Disruptors Attitude Scale as a pre-test. All participants were given a number between 1 and 140 using an internet random number generator. Participants were randomly assigned to interviewing-based education (intervention group) and routine pregnancy care (control group) groups in a 1:1 ratio.

Participants in the intervention group received three face-to-face motivational interviewing-based education (MI) sessions, delivered once weekly, with each session lasting approximately 30–45 min. While there is no consensus in the literature regarding the number of motivational interview sessions, 2–4 sessions are commonly used. Three sessions were used in this study as well. During the first session, participants were provided with information regarding the potential health effects of the products and guidance on how to read and interpret product ingredient labels. Throughout the intervention, the researcher took care to avoid increasing participants’ anxiety. In the second session, participants’ goals related to reducing or discontinuing product use were collaboratively identified, and motivational support was provided to facilitate behavior change. The third session focused on resolving ambivalence and identifying alternative strategies, such as increasing water intake, frequent hand washing, and preparing natural products at home. Participants in the control group did not receive any intervention during the study period. Four weeks after the pretest assessment, both groups completed the posttest measures. Following completion of the posttest, participants in the control group were offered a single informational session covering the content provided to the intervention group, upon request. These stages as outlined in the literature are shown in Table 1 in chronological order.

Table 1.

The planned preparatory stages for Motivational Interviewing

Stage of Change	Session & Timeline	Clinical Goals and Theoretical Focus	Intervention Content and Activities
Contemplation (Thinking)	Session 1: Baseline/Week 1	Engagement and Agenda Setting: Build report and identify baseline usage patterns and readiness to change	• Defining the goals and collaborative nature of the MI process • Assessment of current personal care and domestic chemical product frequency • Determining the participant's self−efficacy and internal motivation for a healthy pregnancy
Preparation/Action (Moving)	Session 2: One week after Session 1	Evoking and Planning: Highlight discrepancies between current behaviors and health goals to resolve ambivalence	• Exploring feelings and anxieties regarding maternal–fetal chemical exposure • Establishing specific, personalized goals for reducing or stopping product use • Providing evidence−based education on reading product labels and using mobile applications for ingredient analysis
Maintenance (Sustaining)	Session 3: One week after Session 2	Consolidation and Problem Solving: Strengthen commitment and address practical barriers to long−term change	• Reviewing progress and psychological shifts since the previous session • Resolving remaining dilemmas or barriers to reduction • Identifying sustainable natural alternatives and encouraging behaviors like frequent hand washing and high−water intake

Statistical analysis

Data was analyzed in SPSS software (version 29.0, SPSS, Chicago, Illinois). Descriptive statistics of continuous variables in the study were shown with mean, standard deviation and descriptive statistics of categorical variables were shown with frequency and percentage. Normality analysis was performed before making comparisons between variables. Since skewness and kurtosis values were between −2 and + 2, it was assumed that the variables showed normal distribution. In descriptive statistics, t-tests and chi-square tests were used to compare two groups. Mann Whitney U test was used to compare differences (pretest–posttest) between the experimental and control groups. Descriptive statistics are presented as median and interquartile range (Q1-Q3), Mean ranks, U values, Z scores and significance level are reported. Statistical significance was set at p < 0.05. The differences between the mean scores of the intervention and control groups on the EDAS (between groups and time) were examined with test, while the difference between time*groups was examined with the mixed design analysis of variance-ANOVA (generalized linear model). The Cohen-d effect value for the difference according to time and between groups and the etasquared (η2) value for the difference on the group*time axis were examined. Etasquared has a value between 0 and 1 and was interpreted as 0.01 indicating a small effect 0.06 indicating a medium effect and 0.14 indicating a large effect.

Ethical aspect

Ethical approval for the study was obtained from the Istanbul University-Cerrahpaşa, Non- Interventional Clinical Research Ethics Committee (No: 2023/62; date: 03 May 2023). Women who met the eligibility criteria were provided with information about the purpose and content of the study; those who agreed to participate were asked to sign the Informed Consent Form. The study was conducted in accordance with the Declaration of Helsinki. Written and verbally informed consent was obtained from all participants after they received a full explanation of the study procedures.

Results

The mean age of the participants was 28.26 ± 5.12, 48.5% (n = 63) were primiparous. 38.5% (n = 50) of the group were university graduates. The baseline characteristics of experimental and control groups are presented in Table 2.

Table 2.

Baseline characteristics of experimental and control groups. (N = 130)

Characteristics		Intervention (n = 69)	Control (n = 61)	Test/p
Age, mean (SD)		27.51 (5.24)	29.11(4.88)	1.80/0.074*
Education,n(%)	Primary	10 (14.5))	7 (11)	1.467/0.480**
	High	35 (50.7)	28 (45.9)
	University	24 (34.8)	26 (42.6)
Working outside home,n (%)	Yes	41 (59.4)	33 (54.1)	0.274/0.872**
	No	28 (40.6)	28 (45.9)
Income,n(%)	Low	3 (4.3)	4 (6.6)	0.153/0.926**
	Moderate	47 (68.1)	40 (65.6)
	High	19 (27.5)	17(27.9)
Parity,n(%)	Primipar	31 (44.9)	32 (52.5)	0.258/0.612**
	Multipar	(55.1)	29 (47.5)
Pregnancy, n (%)	1.Trimester	16 (23.2)	10 (16.2)	1.132/0.568**
	2.Trimester	31 (44.9)	32 (52.5)
	3.Trimester	22 (31.9)	19 (31.1)
Pregnancy plan,n (%)	Planned	39 (56.5)	42(68.9)	1.488/0.223**
	Unplanned	30 (43.5)	19 (31.1)

*Student t test

**Chi square test, p < 0.05

In many products, a statistically significant difference was found when comparing the differences (pre-test-post-test) in personal care product usage between the experimental and control groups. The reduction observed in the experimental group's post-test was greater than that observed in the control group (Except soap, toothpaste, hand moisturizer, nail polish/remover) (p < 0.05). Comparison of differences in personal care product use between pretest and posttest in the intervention and control groups are shown in Table 3.

Table 3.

Comparation of differences in personal care products use between experimental and control groups

Products	Grup	Median (Q1–Q3)	Mean Rank	Sum of Ranks	U	Z	p
Skin products/rinse
Soap	Intervention	0 (‑1–0)	62.88	4339	1924	−0.903	0.367
	Control	0 (‑1–0)	68.46	4176	1924		0.367
Shower gel	Intervention	0 (0–2)	73.86	5096	1528	−2.901	0.004
	Control	0 (0–2)	56.05	3419	1528		0.004
Facial cleaner	Intervention	0 (0–1)	70.7	4878.5	1745.5	−1.994	0.046
	Control	0 (0–1)	59.61	3636.5	1745.5		0.046
Make-up remover	Intervention	0 (0–1)	73.04	5040	1584	−2.874	0.004
	Control	0 (0–1)	56.97	3475	1584		0.004
Facia lmask	Intervention	0 (0–1)	76.14	5254	1370	−3.801	< 0.001
	Control	0 (0–1)	53.46	3261	1370		< 0.001
Toothpaste	Intervention	0 (0–0)	65.17	4497	2082	−0.218	0.828
	Control	0 (0–0)	65.87	4018	2082		0.828
Skin products/leave-in
Body moisturizer	Intervention	0 (0–1)	71.7	4947	1677	−2.428	0.015
	Control	0 (0–1)	58.49	3568	1677		0.015
Hand moisturizer	Intervention	1 (0–2)	67.51	4658.5	1965.5	−0.677	0.499
	Control	1 (0–2)	63.22	3856.5	1965.5		0.499
Facial moisturizer	Intervention	0 (0–2)	83.96	5793	831	−6.444	< 0.001
	Control	0 (0–2)	44.62	2722	831		< 0.001
Tonic	Intervention	0 (0–1)	74.19	5119	1505	−3.489	< 0.001
	Control	0 (0–1)	55.67	3396	1505		< 0.001
Face care cream	Intervention	0 (0–1)	73.96	5103.5	1520.5	−3.109	0.002
	Control	0 (0–1)	55.93	3411.5	1520.5		0.002
Sunscreen	Intervention	0 (0–0)	70.86	4889	1735	−2.472	0.013
	Control	0 (0–0)	59.44	3626	1735		0.013
Eye care cream	Intervention	0 (0–2)	74.9	5168	1456	−3.394	0.001
	Control	0 (0–2)	54.87	3347	1456		0.001
Deodorant	Intervention	1 (0–3)	82.89	5719.5	904.5	−5.969	< 0.001
	Control	1 (0–3)	45.83	2795.5	904.5		< 0.001
Perfume	Intervention	1 (0–2)	79.82	5507.5	1116.5	−4.931	< 0.001
	Control	1 (0–2)	49.3	3007.5	1116.5		< 0.001
Hair products
Shampoo	Intervention	0 (0–1)	76.91	5306.5	1317.5	−4.648	< 0.001
	Control	0 (0–1)	52.6	3208.5	1317.5		< 0.001
Hair conditioner	Intervention	0 (0–1)	74.09	5112.5	1511.5	−3.487	< 0.001
	Control	0 (0–1)	55.78	3402.5	1511.5		< 0.001
Hair color	Intervention	0 (0–0)	69.59	4801.5	1822.5	−2.104	0.035
	Control	0 (0–0)	60.88	3713.5	1822.5		0.035
Hair spray, jelly, mouse	Intervention	0 (0–1)	75.33	5198	1426	−4.104	< 0.001
	Control	0 (0–1)	54.38	3317	1426		< 0.001
Make-up products
Foundation	Intervention	0 (0–0)	70.93	4894	1730	−2.434	0.015
	Control	0 (0–0)	59.36	3621	1730		0.015
Blush	Intervention	0 (0–1)	72.49	5002	1622	−2.649	0.008
	Control	0 (0–1)	57.59	3513	1622		0.008
Eye shadow	Intervention	0 (0–0)	71.43	4929	1695	−2.664	0.008
	Control	0 (0–0)	58.79	3586	1695		0.008
Mascara	Intervention	0 (0–0)	71.37	4924.5	1699.5	−2.71	0.007
	Control	0 (0–0)	58.86	3590.5	1699.5		0.007
Eye pencil	Intervention	0 (0–0)	68.97	4759	1865	−2.078	0.038
	Control	0 (0–0)	61.57	3756	1865		0.038
Lipstick/gloss	Intervention	0 (0–0)	70.7	4878	1746	−2.331	0.02
	Control	0 (0–0)	59.62	3637	1746		0.02
Nail polish/remover	Intervention	0 (0–0)	65.78	4539	2085	−0.175	0.861
	Control	0 (0–0)	65.18	3976	2085		0.861

^*Mann Whitney U Test, p < 0.05

A statistically significant difference was found when comparing the differences (pre-test-post-test) in domestic products that may contain chemicals usage between the experimental and control groups. The reduction observed in the experimental group's post-test was greater than that observed in the control group (p < 0.05). Comparison of differences in domestic chemicals use between pretest and posttest in the intervention and control groups are shown in Table 4.

Table 4.

Comparison of differences in domestic products that may contain chemicals

Products	Grup	Median (Q1–Q3)	Mean Rank	Sum of Ranks	U	z	p
Detergent	Intervention	0 (0–1)	74.64	5150	1474	−3.456	0.001
	Control	0 (0–1)	55.16	3365	1474		0.001
Softener	Intervention	0 (0–1)	75.75	5227	1397	−3.616	< 0.001
	Control	0 (0–1)	53.9	3288	1397		< 0.001
Bleach,	Intervention	0 (0–1)	75.08	5180.5	1443.5	−3.517	< 0.001
	Control	0 (0–1)	54.66	3334.5	1443.5		< 0.001
Descaler	Intervention	0 (0–1)	74.94	5171	1453	−3.618	< 0.001
	Control	0 (0–1)	54.82	3344	1453		< 0.001
Floorcleaner	Intervention	0 (0–1)	74.3	5127	1497	−3.141	0.002
	Control	0 (0–1)	55.54	3388	1497		0.002
Dishwashingdtr	Intervention	0 (0–1)	74.59	5147	1477	−3.486	< 0.001
	Control	0 (0–1)	55.21	3368	1477	−1.407	< 0.001
Scentedcandle	Intervention	0 (0–0)	68.91	4754.5	1869.5	−2.039	0.041
	Control	0 (0–0)	61.65	3760.5	1869.5		0.041
Petbottle	Intervention	1 (0–2)	78.83	5439	1185	−4.549	< 0.001
	Control	1 (0–2)	50.43	3076	1185		< 0.001

^*Mann Whitney U Test, p < 0.05

Results of Endocrine Disruptors Attitude Scale (EDAS)

While the pretest EDAS mean scores of the pregnant women in the intervention and control groups were similar, the posttest EDAS mean scores increased. The increase in the score in the intervention group was 4.85 points (7.1%), while this increase was 1.7 points (2.5%) in the control group. Results indicated significant main effect for group assignment (F8.76; η² = 0.064, p = 0.004), a significant main effect for time (F57.448; η² = 0.310, p < 0.001), and a significant interaction between group and time (F13.06; η² = 0.093, p < 0.001). The effect size of the difference between the groups according to time was moderate. Comparison of pretest- posttest EDAS Scores of Intervention and Control Groups are presented Table 5.

Table 5.

Comparison of pretest-post test endocrine disruptors attitude scale (EDAS) scores of intervention and control groups

		Intervention(n = 69)	Control(n = 61)	tgrup/p/d?
EDAS	Pre-test	68.12 (7.69)	66.61 (6.52)	1.256/0.211/-
	Post-test	72.97 (5.45)	68.31 (5.81)	4.713/ < 0,001/0.828
b tttime/p/d		−6.742/ < 0.001/0.812	−3.955 < 0,001/0.506
Fgroupc/p/pη2		8.764	0.004	0.064
c Ftime/p/pη2		57.448	< 0.001	0.310
c Fgroup*time/p/pη2		13.069	< 0.001	0.093

^aIndependent groupt-test

^bDependent groupt-test

^cAnalysis of Variance (ANOVA)for repeated measures,d:Cohen’sdvalue, pη2: partial eta square, p < 0.05

Discussion

In this study, we found that face-to-face MI-based education during pregnancy reduced the use of personal care and domestic products that may contain chemicals was effective in demonstrating a positive attitude to protect against endocrine disruptors.

Many studies indicate that women make limited changes in their use of chemical-containing products during pregnancy [3, 19–21]. These studies highlight heterogeneity in terms of product categories (cosmetics, makeup, personal care, household products) and duration of use (last 24 h, last week). This heterogeneity makes it difficult to compare study results. While some studies focus only on the use of hair and body cleaning products within the scope of personal care products; some focus on the use of cosmetics and make-up products in addition to cleaning products [22, 23]. It is noteworthy that there are even fewer studies focusing on the use of household products and food packaging products compared to personal care and cosmetic products [21].

A growing body of intervention research has examined strategies to reduce exposures to chemicals associated with personal care products, household products, and diet. Previous studies have often focused on direct modification of exposure sources (e.g., removal or replacement of products) [24–29], or education-based lifestyle intervention strategies aimed at reducing use of products containing bisphenols, phthalates, and other endocrine-disrupting compounds [30–38]. For example, interventions that provided replacement personal care products free of specific chemicals resulted in measurable decreases in urinary biomarkers of phthalates and phenols within a short timeframe, demonstrating that modifying exposure sources can reduce internal dose biomarkers under controlled conditions [20]. Some studies examine the impact of policy changes [39–42]. Sieck et al., in their study reviewing 58 primary articles, reported that although many interventions were effective, policy-level interventions had the greatest impact [43].While these studies provide important evidence that reducing or replacing exposure sources can alter biomarker of toxicants, many rely primarily on directive strategies such as product substitution, education, or short-term restrictions, rather than actively engaging participants’ motivation or readiness to change. In contrast to these approaches, our intervention integrated motivational interviewing techniques designed to explore participants’ personal motivations, ambivalence, and readiness for behavior change regarding the use of personal care and household products that may contain potentially harmful chemicals. Although it was not within the scope of this study to directly compare motivational interviewing with traditional education-only approaches, our findings align with broader literature suggesting that individual-level motivation and compliance are important determinants of intervention success [43].

Interventional studies performed on pregnant women are limited. Six studies were found to focus on interventions aimed at reducing chemical products use in pregnant women. Three of these included the use of other products instead of products containing endocrine disruptors through national/local policy changes [40, 41, 44]. In these studies, it was found that biomarkers of certain endocrine disruptors in some products decreased by banning their use, but new generation product metabolites increased and replaced them. These results show that political regulations cannot be the only way. Another interventional study focused on dietary changes in pregnant women and reported that there was no decrease in biomarkers after a 3-day diet reducing phthalate exposure. Researchers emphasized that participants had difficulty complying with the restrictive diet and mentioned the difficulty of sustainability of such restrictive diets [15]. There are two studies that include workshops and information-giving initiatives on diet and behavior change during pregnancy [36]. Wu et al., determined that some chemical product metabolites in urine decreased after written recommendations to 35 pregnant women, including changing dietary habits (suggesting fresh and nutritious foods, restricting fast food and canned foods), gaining a lifestyle habit (restricting personal care product use, proper exercise) and environmental regulations (Faraway second-hand smoking, limited transport with car) [36]. El Ouazzani [44] found a decrease in fast food nutrition and some metabolites after the intervention, but no change was found in canned food intake [44]. The results of all these studies that included initiatives to reduce chemical product use in pregnant women show that policy development cannot be the only way, dietary changes and product use restrictions are not sustainable and do not consider the motivation of individuals to comply with the new recommended diet and behaviors. In this case, motivating individuals and taking their priorities into account in reducing the use of chemicals is extremely decisive in terms of the effectiveness of the interventions. Meta-analysis results support the fact that motivational interviewing (MI) techniques, which aim to increase motivation for change, are effective in gaining and maintaining many healthy behaviors or in stopping risky behaviors [45, 46]. MI during pregnancy has been reported to be effective in situations such as deciding on the type of delivery, controlling gestational weight gain [14, 16].Considering all these findings, it is seen that MI-based education, which is structured as in our study, is an effective method in terms of providing information about chemical products, creating motivation for behavioral change, and leaving the woman the choice and priorities regarding the products she can cut/reduce. Thus, women are informed about the subject, their self-efficacy is supported, and the choice of behavioral change is left to them. Our results show that after the intervention, women mostly stopped using make-up products, deodorant, perfume and facial moisturizer. In parallel with our result, Ficheux et al., [17] reported in their cross-sectional descriptive study with French pregnant women use some chemical products more than non-pregnant women, and that the first product category they give up is make-up products [17]. Similarly, Teysseire et al., mentions that the use of deodorant and perfume decreases during pregnancy [7].

These research findings provide evidence of the effectiveness of an easy-to-implement, low- cost method for reducing the use of chemical products during pregnancy. We believe that this evidence will provide perspective to all health care professionals working with pregnant women and motivate them to include chemical product use reduction initiatives in their clinical practices.

Limitations and strengths

In this study, the comparison of the differences in the results of the intervention group over time with the results of a control group is strength of the study. The fact that the attitudes of individuals towards endocrine disruptors were assessed with a standard scale is strength. The study sample consisted largely of women with higher educational attainment and relatively few participants from low-income households. This may limit the generalizability of our findings to more socioeconomically disadvantaged populations, who are often the most difficult to reach. Although motivational interviewing has demonstrated effectiveness across diverse socioeconomic contexts, future research should prioritize the inclusion of families with lower income and educational levels to better evaluate the applicability and impact of this intervention in these groups.

The researcher who conducted the interview and conducted the surveys was the same person, and therefore blinding could not be done. Another limitation of the study is that the changes in the amount of products used over time are based on the individuals' own statements and do not include any measurements. However, having a control group in our study is an important precaution against this limitation. The study results are limited to the sample and cannot be generalized. Given the exploratory nature of the analyses, no formal correction for multiple comparisons was applied; results should therefore be interpreted with caution.

An important limitation of this study is that products with structurally different patterns of use were assessed using the same measurement approach. Additionally, due to the nature of pregnancy, the sustainability of the observed effects could not be evaluated, and therefore no conclusions can be drawn regarding the duration of the intervention’s impact. Although the EDAS assesses changes in perceptions related to product use, it does not capture changes in preferences following the intervention. Accordingly, the present study focuses solely on the frequency of product use and does not examine post-intervention changes in other relevant product-related behaviors (e.g., label reading practices, preference for organic products). This represents a potential limitation of the study.

Conclusion

This study shows that motivational interviewing-based education (MI) is an effective method in reducing the use of personal care products and domestic products that may contain chemicals and create attitude changes in protection from endocrine disruptors in the perinatal period. MI is an easy to use and effective method that considers the motivation, personal priorities and preferences of the woman and supports her autonomy.

Authors’ contributions

NYA and NKO performed data analysis and concept, contributed to the study design and implementation. NKO has done supervision and critical review. NYA was responsible for materials, data collection and literature review. All authors approved the final version.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

All data requests should be submitted to the corresponding author for consideration as agreed in our publication plan. Access to anonymized data may be granted following review with the corresponding author. Deidentified data collected and presented in this study, including individual participant data and a data dictionary defining each field in the set, will be made available upon reasonable request after publication of this Article, following approval by regulatory authorities. Data can be requested by contacting the corresponding author.

Declarations

Ethics approval and consent to participate

Ethical approval for the study was obtained from the Istanbul University-Cerrahpaşa, Non- Interventional Clinical Research Ethics Committee (No: 2023/62; date: 03 May 2023). Women who met the inclusion criteria were given information about the purpose and content of the study, and those who agreed to participate were asked to sign the Informed Consent Form. The written and verbal permission from the participants, written and verbal consent to participate and the Declaration of Helsinki was adhered to. The study was registered retrospectively with the Clinical Trials Protocol Registration and Results System. NCT06380634. (registered 24.04.2024).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.