Working During Pregnancy

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Working during pregnancy
Authors: Josephine R Fowler, MD, MSc, FAAFP, Larry Culpepper, MD, MPH
Section Editor: Charles J Lockwood, MD, MHCM
Deputy Editor: Kristen Eckler, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2018. | This topic last updated: May 02, 2018.
INTRODUCTION — Worldwide, women are working during all trimesters of pregnancy for reasons including financial necessity, preservation of insurance, career advancement,
and preservation of postpartum leave time. Working pregnant women often request advice and assistance from their clinicians to manage challenges that occur while being
pregnant at work. This topic will review issues including the impact of pregnancy on work, the impact of work on pregnancy, workplace exposure, leave time and discrimination,
and requesting accommodations to enable pregnant women to continue working.
Topics related to occupational risks and exposure are presented separately.
● (See "Overview of occupational and environmental risks to reproduction in females".)
● (See "Occupational and environmental risks to reproduction in females: Specific exposures and impact".)
● (See "Overview of occupational and environmental health".)
PREVALENCE — In the United States, the percentage of women in the labor force rose from 30 to nearly 60 percent between 1950 and 2000 [1]. For 2016, 57 percent of
women ages 16 years and older were anticipated to be in the workforce. Of women with children under 18, 70 percent are in the labor force [2,3]. Globally, 67 percent of women
in developed countries between the ages of 15 to 64 years were employed in 2014 [2]. As the number of women in the workforce has risen, so has the number of women
working while pregnant. As an example, for women pregnant with their first child, 66 percent of mothers worked while pregnant in 2008 compared with only 44 percent in the
early 1960s [4]. In addition, women are working later into their pregnancies than ever before. In the early 1960s, 65 percent of pregnant women stopped work more than a month
prior to delivery, while 35 percent continued working in their final month of pregnancy. By the late 2000s, the pattern had reversed, with 82 percent of pregnant women working
until within one month of delivery and 18 percent stopping work earlier. More women are also returning to work within six months after their first birth than in previous decades (21
versus 73 percent from the early 1960s to the period of 2005 to 2007).
IMPACT
Pregnancy on work performance — Pregnancy is associated with a wide variety of physical, functional, and emotional changes. While many women work while pregnant
without any interference from pregnancy-related changes, problems of nausea and vomiting, pain, and fatigue can negatively impact a woman's work performance. (See "Clinical
manifestations and diagnosis of early pregnancy".)
● Nausea and/or vomiting – Nausea and/or vomiting can be provoked by workplace odors or restrictions around eating [5]. These problems can usually be managed with
hydration, snacking as needed, taking a brief break, medication, and scheduling the most demanding work for times when the woman tends to feel less nauseous, if
possible. Clinicians may need to request accommodations for their patients to allow for such non-medical interventions. In cases of severe vomiting requiring intensive
outpatient intravenous or hospital-based therapy, a short-term absence from work can be necessary. (See "Treatment and outcome of nausea and vomiting of pregnancy".)
● Fatigue – In an interview study of first-time pregnant working women, the dominant theme was described as "living on the edge of being overstretched" [6]. Being exhausted
from adapting to professional life while pregnant was a major contributor to this theme.
● Discomfort and pain – By the end of the second trimester and continuing through term, physical and physiologic changes can bring on heartburn, back pain, joint pain,
varicose veins, hemorrhoids, and physical discomfort from the enlarging uterus. Ideally, the woman and her employer will be able to make reasonable adjustments to deal
with these discomforts in the workplace. Simple precautions that can help reduce excessive fatigue, discomfort, and potentially reduce the risk of pregnancy complications
include modifying shift times and tasks; minimizing lifting, bending, and prolonged standing; using proper lifting techniques; taking regular breaks every few hours and a
longer break after five hours; and drinking plenty of fluids [7-13]. However, lost work time and interruptions in workflow can be necessary. (See "Maternal adaptations to
pregnancy: Musculoskeletal changes and pain".)
● Cognitive function – A meta-analysis of 20 studies, including over 700 pregnant women, found that general cognitive functioning (standard mean differences [SMD] 1.28;
95% CI 0.26-2.30), memory (SMD 1.47; 95% CI, 0.27-2.68), and executive functioning (SMD 0.46; 95% CI, 0.03-0.89) were significantly reduced during the third trimester of
pregnancy but not during the first two trimesters [14]. Longitudinal studies found declines between the first and second trimesters in general cognitive functioning (SMD 0.29;
95% CI, 0.08-0.50) and memory (SMD 0.33; 95% CI, 0.12-0.54) but not between the second and third trimesters [14]. Pregnant/postpartum group report more subjective
difficulties with memory, mood, and quality of life than control women [15]. More data are needed to understand the impact of pregnancy on cognitive function.
Work on pregnancy and child development — Despite data limitations, working while pregnant generally does not appear to negatively impact maternal or fetal health. The
effect of work on pregnancy outcome is difficult to assess because available data are often contradictory, largely retrospective, and subject to multiple sources of bias, including
inadequate adjustment for confounders, recall bias, selective participation, and subjective assessment of exposures. In particular, a potential bias in observational studies of
outcomes of pregnant women who work or do not work is the "healthy worker" effect whereby healthier workers are more likely to continue to work and work in more demanding
jobs than women with less robust health.
● Pregnancy – Systematic reviews have generally concluded that standard working conditions present little hazard to maternal or child health [16,17]. A woman with an
uncomplicated pregnancy who is employed where there are no greater potential hazards than those encountered in routine daily life may continue to work without
interruption until the onset of labor. However, the physical demands of the woman's job are evaluated on a case-by-case basis, especially in women who have medical or
obstetrical disorders that are unstable or associated with impaired placental perfusion (eg, preeclampsia, fetal growth restriction). As an example, studies of the effect of
work on a woman's risk of developing hypertension during pregnancy generally report no significant association; however, the risk may depend on the occupational
classification [18-20]. While available evidence is inadequate to support a change in occupational responsibilities for prevention of pregnancy-related hypertensive disorders,
limited data do support changes in physical activity in the management of some women who develop these disorders. (See "Preterm birth: Risk factors, interventions for risk
reduction, and maternal prognosis", section on 'Occupational physical activity' and 'Selected workplace exposures' below.)
● Child development – Assessing the impact of maternal employment on children's development is difficult because of selection bias and missing data (eg, quality of
childcare, home environment, maternal sensitivity to the child's needs, paternal factors). While the literature is conflicting, the body of evidence generally reports that if there
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are any adverse effects of maternal employment on child development, these effects are likely to be small [21-23].
Women in lower socioeconomic groups may represent an exception to the above information. In a 2014 survey study of 1400 pregnant French workers, women classified as
deprived were more likely to encounter occupational hazards, have three or more occupational exposures during a pregnancy, and, for those with three or more occupational
exposures, have a preterm delivery when compared with non-deprived women [24,25]. Similarly, in a study from the national Swedish Registry, low levels of job control and high
levels of physical demands and job hazards were more common in manual compared with non-manual labor classes. In multivariate analyses, class differences in maternal
working conditions explained 14 to 38 percent of low-birth-weight births and 20 to 46 percent of preterm births [26].
WORK CHARACTERISTICS
Hours, shift, and type of work — For women with healthy uncomplicated singleton pregnancies, the Royal College of Physicians (RCP) and the Faculty of Occupational
Medicine (FOM) of the United Kingdom concluded that available evidence did not justify imposing mandatory restrictions to working hours, shift work, lifting, standing, and
physical work during pregnancy [17]. Challenges to writing such guidelines include lack of data demonstrating a clear cut-off at which work is detrimental to the health of most
women and fetuses as well as the reality that some women must continue working while pregnant for economic reasons, regardless of medical advice. Any guidelines must also
balance data suggesting that some level of physical activity while pregnant is healthy. Both the Royal College of Obstetricians and Gynaecologists (RCOG) and the American
College of Obstetricians and Gynecologists (ACOG) state that physical activity during pregnancy is beneficial to most women, exercise is safe for both mother and fetus, and
exercising while pregnant carries little risk [27,28]. In addition, abstaining from work can create hardships that need to be considered and balanced with the anxiety and
uncertainty of possible low levels of risk. (See "Exercise during pregnancy and the postpartum period".)
One United States analysis of "occupational physical activity" reported that high activity levels were significantly associated with small for gestational age (SGA) for the highest
quartile compared with lowest quartile and were also positively associated with preterm birth [29]. In contrast, analysis of the impact of nonoccupational activity suggests that low
physical activity may increase at least preterm birth risk compared to higher levels [30]. While activity during pregnancy is generally encouraged, the point at which extreme
activity, such as that imposed by extended work hours, shift work, and heavy work, transitions from benefit to harm is less clear, in part because data are derived from
observational studies, the definition of important outcomes varies by patient, and women interpret and tolerate risk differently. Thus, the physical demands of the woman's job
should be considered on a case-by-case basis, especially in women at higher risk of preterm delivery or who have medical or obstetrical disorders that are unstable or
associated with impaired placental perfusion (eg, preeclampsia, fetal growth restriction).
The RCP/FOM guideline reported that long working hours (>40 hours per week), shift work (working a schedule other than 7 AM to 5 PM five days a week), prolonged standing
(>3 to 4 hours of continuous standing), and lifting and heavy physical work may increase the risk of preterm delivery, SGA infant, miscarriage, and pregnancy-associated
hypertension to a small degree, but the confidence intervals for many of the variables were not significant, and thus the data are also compatible with no effect (or even a small
benefit) from work [17]. The uncertainty in the estimated risk reflected both the amount and quality of available evidence. These findings are generally consistent with those
reported in other systematic reviews and meta-analyses [11,12]. These job requirements may be more common in pregnant women than previously thought. In one large
nationally representative data set, 31 percent of women reported standing for more than 75 percent of their time at their jobs [31].
A different review of studies assessing the impact of fixed and rotating shift work schedules reported that while the studies were not conclusive, the evidence suggested that both
work schedules were associated with menstrual cycle disturbances and miscarriages [32]. However, the effect size was uncertain. In a retrospective study of 440 female
employees in a semiconductor factory, persistent rotating shifts among factory workers was associated with lower birth weights compared with fixed or intermittently rotating
shifts [33].
Lifting — In 2013, the National Institute for Occupational Safety and Health (NIOSH) published clinical guidelines for occupational lifting in uncomplicated pregnancies [10]. The
recommended weight limits are based on gestational age, intermittent versus repetitive lifting, time (hours/day) spent lifting, and lifting height from floor and distance in front of
body. In this guideline, the maximum permissible weight for a woman less than 20 weeks of gestation performing infrequent lifting is 36 pounds (16 kg) and the maximum
permissible weight at ≥20 weeks is 26 pounds (12 kg). For repetitive lifting ≥1 hour/day, the maximum weights in the first and second half of pregnancy are 18 pounds (8 kg) and
13 pounds (6 kg), respectively, and for repetitive lifting <1 hour/day, the maximum weights are 30 pounds (14 kg) and 22 pounds (10 kg), respectively. Although not based on
high-quality evidence, these guidelines are a reasonable reference for counseling pregnant women.
Individual studies provide risk estimates in subpopulations of women. For example, a study based on the Danish National Birth Cohort (1996 to 2002) of over 71,500
occupationally active women assessed the relationship between total weight lifted per day and miscarriage, which was not evaluated in the above guideline [13]. Compared to
non-lifters, the hazard ratio (HR) for early miscarriage (≤12 weeks) increased in women who lifted a large amount of weight over the course of the day: 101 to 200 kg total weight
lifted per day HR 1.38 (95% CI 1.10-1.74) and >1000 kg total weight lifted per day HR 2.02 (95% CI 1.23-3.33). Late miscarriage (13 to 21 weeks) was associated with total daily
weight load but not with number of lifts per day. No association was found between occupational lifting and stillbirth. The study was adjusted for daily smoking, alcohol
consumption, leisure-time physical exercise, leisure-time daily lifting, and predominant working posture (ie, primarily standing or walking, primarily sitting, or varying).
Stress — Whether working while pregnant increases or decreases a woman's overall stress likely depends on the woman's individual circumstances. As stress has been
associated with poor reproductive outcomes, clinicians are encouraged to ask women about all sources of stress in their lives. In a national population-based control study in the
United State, the most common source of emotional stress at work was dealing with unpleasant or angry people [31]. Women who identified as non-Hispanic Black or Hispanic
were more likely to be in jobs in which they had to address angry or unpleasant people ≥75 percent of the time compared with non-Hispanic white women or women who
identified as other.
While issues related to work, the occupational setting, and job requirements may increase stress, they also may have a positive influence both directly (eg, social support from
coworkers) and indirectly (eg, income stability, maintenance of medical insurance, available nutrition, protection from interpersonal violence) [34]. In addition, significant stressors
can develop in non-work-related aspects of the patient's life (eg, childcare, family illness). The influence of psychosocial factors on pregnancy outcomes may occur either directly
via physiological pathways, or indirectly via behavioral pathways, or both. Psychosocial stress may also lead to unhealthy behaviors, including key behavioral risk factors for
preterm birth such as poor diet/nutrition and smoking.
Maternal-placental-fetal neuroendocrine, immune/inflammatory and vascular processes all are responsive to stress, participate in the physiology of parturition, and may provide
biological pathways that influence pregnancy outcome [35]. Stress is a common element activating a series of physiologic adaptive responses in the maternal and fetal
compartments. Emerging data suggest that greater cardiovascular and neuroendocrine responses to acute stressors are predictive of poorer birth outcomes, but data are limited
[34]. In addition, maternal stress may also play a role in the development (or mis-development) of neural networks, also known as the connectome [36]. One response involves
activation of the hypothalamic-pituitary-adrenal (HPA) axis with increased secretion of corticotropin-releasing hormone (CRH), which can initiate preterm birth [37]. Another
response involves chronic extended activation of the sympathetic nervous system with increased secretion of catecholamines, which may decrease uterine blood flow and, in
turn, lead to increased secretion of placental CRH [9]. While a population-based cohort study reported that psychosocial work stress (high demands and low control) was not
associated with an increased risk of congenital malformations, outcomes such as preterm birth, low birth weight, and hypertensive disorders of pregnancy were not studied [38].
(See "Pathogenesis of spontaneous preterm birth", section on 'Activation of the HPA axis'.)
SELECTED WORKPLACE EXPOSURES — The impact of selected workplace exposures on pregnancy outcomes are reviewed below. These issues, as well as exposure
prevention, are presented in greater detail separately:
● (See "Overview of occupational and environmental risks to reproduction in females".)
● (See "Overview of occupational and environmental health".)
Obligations of employer — United States employers are mandated by law to provide information regarding work exposures that might affect reproductive outcomes (table 1).
Exposure to these potential hazards should be minimized or avoided but do not necessarily warrant leaving the job. Some examples of potential hazards include [9]:
● Pharmaceuticals
● Battery acid
● Benzene
● Dyes used in manufacturing
● Formaldehyde
● Heavy metals
● Solvents
● Pesticides and herbicides
● Printing inks
● Radiation
● Products used in rubber, plastics, and textile manufacturing
● Wood preservatives
The Occupational Safety and Health Administration (OSHA) sets and enforces standards requiring employers to provide a workplace free from recognized hazards likely to
cause serious physical harm. Every employer is mandated to have Hazard Communication Safety Data Sheets that contains information on chemicals that might cause hazards
in the workplace. This format is more uniform than the older Material Safety Data Sheets. This sheet gives valuable information about pregnancy risk as well as the ingredients of
a particular chemical, its appearance and odor, flammability, health hazards, reactivity data, precautions, spill and exposure procedures, preventive measures, and first aid
measures.
Additional information on potential teratogens can be found at the following resources:
● The National Institute for Occupational Safety and Health (NIOSH) of the US Centers for Disease Control and Prevention.
● National Library of Medicine (NLM)
Bethesda, MD
800-638-8480
● Reprotox
Columbia Hospital for Women Medical Center
Washington, DC
202-293-5137
● Teratogen Information System (TERIS)
University of Washington
Seattle, WA
206-543-2465
● Pregnancy Exposure Registries
● MotherToBaby, Organization of Teratology Information Specialists (OTIS)
● The Hospital for Sick Children
Toronto, Canada
877-439-2744
● Pediatric Environmental Health Specialty Units (PEHSU)
Impact of exposure
Industry-related
● Lead – Lead is the third most common occupational exposure in women and has been linked to a variety of adverse outcomes, including spontaneous abortion and
impaired cognitive development. (See "Occupational and environmental risks to reproduction in females: Specific exposures and impact", section on 'Lead'.)
Under federal and state law, employers should have written lead standards and air monitoring results. Symptoms of lead toxicity (fatigue, muscle and joint pain, abdominal
cramps, headaches, and irritability) appear when lead levels are between 60 and 120 mcg/dL in the blood. OSHA recommends a lead level less than 30 mcg/dL to prevent
reproductive problems. However, neurologic, hematologic, and reproductive effects may occur at lower levels [39]. In pregnant women, blood lead elevations of 20 mcg/dL
are of high concern because of the potential for adverse effects on the developing fetus, which is more susceptible to lead's toxic effects. Even lead levels less than 10
mcg/dL may be of concern in pregnancy in light of studies demonstrating intellectual impairment in children with blood lead concentrations below 10 mcg/dL.
Women working in known areas of lead exposure should always wear protective clothing, change work clothing and shoes before going home, use respiratory equipment to
avoid inhalation, and wash hands before handling food and drinks [40]. The following figure illustrates the approach to management of women based on their serum lead
level (figure 1). Additional information about the impact of lead exposure can be found separately:
• (See "Adult occupational lead poisoning", section on 'Pregnancy and breastfeeding'.)
• (See "Childhood lead poisoning: Exposure and prevention", section on 'Prenatal exposure'.)
● Mercury – The workplace is the major source of mercury exposure. While inhaling metallic mercury over time can affect all systems in the body, the brain and kidneys are
the most likely to be affected at lower levels. In pregnancy, exposure to mercury can be associated with multiple adverse effects. (See "Occupational and environmental risks
to reproduction in females: Specific exposures and impact", section on 'Mercury' and "Mercury toxicity".)
Mercury can be found in elemental, inorganic, and organic forms. Elemental mercury is inhaled through vapors and fumes and is the least absorbed form of mercury.
Persons working in light bulb manufacturing facilities, dental facilities, and gold-mining industries in undeveloped countries where mercury fumes are high have the greatest
risks of elemental exposures. Women working with dental amalgam are at risk of exposure to elemental mercury. Inorganic mercury is found in fungicides, antiseptics and
disinfectants and may be absorbed in toxic levels through the skin. Organic mercury is consumed by eating fish with high levels of methylmercury. (See "Fish consumption
and docosahexaenoic acid (DHA) supplementation in pregnancy".)
Mercury testing is indicated in patients at risk of high mercury exposure or who have symptoms of mercury toxicity [41,42]. Urine is used to test for exposure to elemental
mercury (metallic mercury vapor, inorganic mercury). Blood or scalp hair is used to monitor exposure to methylmercury. (See "Mercury toxicity".)
● Pesticides – Every class of pesticide (organophosphates, carbamates, pyrethroids, herbicides, fungicides, fumigants, organochlorines) appears to have at least one agent
capable of negatively affecting a reproductive or developmental endpoint in animals or humans. Epidemiologic studies have reported adverse reproductive or developmental
outcomes with mixed pesticide exposure in occupational settings, particularly when personal protective equipment was not used [43,44]. In a population-based case-control
study assessing the association of organochloride pesticides and polychlorinated biphenyls (PCBs) with autism and intellectual disability (without autism), higher maternal
serum levels of PCBs were associated with both conditions [45]. Strengths of the study included use of stored second-trimester serum to assess exposure and controlling for
confounding that may have resulted from demographic factors. Counseling patients who are concerned about reproductive and developmental effects of pesticides involves
helping them assess their degree of exposure, weighing risks and benefits of this exposure, and adopting practices to reduce or eliminate exposure and absorption. (See
"Occupational and environmental risks to reproduction in females: Specific exposures and impact", section on 'Pesticides' and "Organophosphate and carbamate
poisoning".)
● Solvents – Occupational exposure to solvents (eg, glycol ethers, carbon tetrachloride, trichloroethylene, methylene chloride) ranges from exposure to known toxic chemicals
in the workplace to exposure to routine household solvents used for cleaning. Household solvents are usually not a major risk since exposure is episodic and air levels are
low. However, women with industrial exposure appear to be at some risk [46-49], which depends on dose and duration of exposure. Exposure to organic solvents has been
linked to congenital heart disease. In addition, one study has reported a possible association between maternal exposure to polycyclic aromatic hydrocarbons (PAHs) and an
increased risk of craniosynostosis in the offspring [50]. Both maternal and paternal occupational exposures have been linked to sporadic retinoblastoma [51,52]. PAHs are
used in a number of jobs, including the oil and gas industries, coal-fired and other power plants, and restaurants. (See "Overview of occupational and environmental risks to
reproduction in females", section on 'Interference with fetal development'.)
We advise women working with occupational solvents to request information regarding the solvent from their employers, work in well-ventilated areas, and wear protective
gear such as masks, gloves, and clothing while using these solvents [40].
Health care
● Pharmaceutical – Health care, veterinary, and some agricultural workers may be exposed to hazardous pharmaceutical agents. Exposure can occur through direct or
indirect contact with these substances [53]. Although health care facilities recommend universal precautions, employees should ask for a Safety Data Sheet (SDS) when
they work in areas exposed to hazardous materials. Hazardous materials should be prepared in well-ventilated areas, handlers should wear protective clothing (double
gloves, gowns, eye protective gear), and all spills should be cleaned immediately and cleaning material discarded properly. Employers should provide training sessions to
employees about hazardous materials in the workplace. It is required to have guidelines and procedures on handling and storage, use, preparation, cleaning spills,
decontamination, first aid measures, handling accidental release, and firefighting measures.
Occupational exposures to chemotherapeutic agents have been linked to some adverse pregnancy outcomes. In a meta-analysis of seven studies, exposure to
chemotherapy was associated with an increased risk of spontaneous abortion (odds ratio [OR] 1.46, 95% CI 1.11-1.92) but not with congenital malformations (OR 1.64, 95%
CI 0.91-2.94) or stillbirths (OR 1.16, 95% CI 0.73-1.82) [54]. Evidence supporting an association between occupational exposure to inhalational anesthetics and reproductive
toxicity is weak and biased from studies performed in the pre-scavenging era.
● Infection – Health care workers in particular are exposed daily, and often repetitively, to infectious agents (table 2). The likelihood of adverse sequelae if a pregnant woman
becomes infected depends on several factors, including the type of infection and the trimester during which the exposure occurred (refer to individual topic reviews on each
infection). Pregnant women working in health care facilities should always use universal precautions when coming in contact with children or adults who may have an
infectious disease and should have appropriate immunizations before and during pregnancy (see "Immunizations during pregnancy").
Radiation — The United States Nuclear Regulatory Commission (NRC) lists limits for prenatal radiation exposure [55,56]. Women should not be exposed to more than 5 mSv
during the nine months of pregnancy and no more than 0.5 mSv during any gestational month. Women working in an environment with radiation exposure should wear a
dosimeter badge, which is processed every two to four weeks. They should also be encouraged to wear proper shielding (eg, lead apron) if exposure is expected, minimize the
time of exposure, and maximize their distance from the source of radiation. The risks of radiation exposure in pregnancy are discussed in detail separately. (See "Diagnostic
imaging in pregnant and nursing women".)
Non-ionizing radiation (eg, electromagnetic fields emitted from computers, microwave communication systems and ovens, power lines, cellular phones, household appliances,
heating pads and warming blankets, airport screening devices for metal objects) appear to have minimal reproductive risk. Video display terminals (VDTs) emit very low
frequency and extremely low frequency electromagnetic fields. Literature reviews have generally concluded that there is no evidence of a significant association between a
woman's use of a VDT and fetal loss or other adverse reproductive outcomes [57,58]. However, ergonometric issues related to use of computers in the workplace (eg, carpal
tunnel syndrome, low back pain) may be more problematic for pregnant women. (See "Radiation risk to healthcare workers from diagnostic and interventional imaging
procedures".)
Environmental
● Heat – The human fetus' temperature is approximately 1°C higher than the maternal temperature. Animal studies suggest that perinatal risks (eg, central nervous system,
vascular disruption, neural defects [59]) increase with maternal heat exposure. Similar findings were found in human studies related to febrile illnesses, sauna use, and hot
tub use [60-62].
The National Institute of Occupational Safety and Health (NIOSH) guidelines address protection of workers in hot environments [63]. Employers of facilities with risk for high
temperature should institute measures to minimize environment and metabolic heat exposure (eg, good ventilation to draw steam and heat from work areas, cooling fans,
heat shields, labor saving devices, rest periods in cooler areas, hydration) and provide training to employees on how to recognize heat-related illnesses. In areas where heat
is unavoidable, employees should take precautions to avoid heat stress and heat-related complications. Pregnant women should be encouraged to increase fluid intake,
request periodic breaks from the heated area, and dress in light clothing to avoid overheating. A resource sheet on Reproductive health and the workplace: Heat is available
from the NIOSH.
● Cold – All workers exposed to extreme cold are at risk of cold stress, which may be exacerbated by vasodilation from pregnancy. There are limited data on the effect of
environmental cold stress on pregnancy outcome, including a few studies on therapeutic hypothermia. (See "Cardiopulmonary arrest in pregnancy", section on 'Post-arrest
care'.)
For women who work outdoors in cold climates, dressing appropriately and taking care to avoid falling on icy surfaces is practical advice. A resource sheet on Cold stress is
available from the NIOSH.
● Noise – Most countries have regulations about occupational noise exposure, but these standards typically do not specifically address pregnant women and fetal safety. In
the United States, the NIOSH recommends that workers should not be exposed to noise at a level that amounts to more than 85 decibels (dB) for eight hours [64]. The
NIOSH has published a fact sheet on Controls for noise exposure. There is no method for shielding the fetus from environmental noise.
Discordant findings have been reported for the effect of noise exposure on birth weight and length of gestation [65,66]. Environmental noise, if sufficiently loud, may damage
fetal hearing, although data in humans are limited [67-71]. In one well-designed prospective national cohort study, those working full-time with <20 days of leave during
pregnancy and ≥85 dB exposure had a hazard ratio of 1.82 (95% CI 1.08-3.08) for hearing dysfunction compared to those with <75 dB exposure. By the 20th week of
gestation, the structures of the fetal auditory system are well-developed, enabling the fetus to detect sounds after the late second trimester of pregnancy [72]. Low-frequency
sounds penetrate the maternal tissues and amniotic fluid more effectively than higher frequency sounds: external noise is minimally reduced for frequencies below 0.5 kHz
but reduced by 40 to 50 dB for frequencies above 0.5 kHz [73].
● Airborne – Women who work outside in urban areas have more exposure to air pollution than other individuals. Numerous studies have examined the links between various
airborne pollutants and adverse outcomes, such as low birth weight, preterm birth, and small for gestational age birth, and have come to different conclusions because of
difficulties in measuring exposures, timing of measurements, and degree of adjustment for confounding. (See "Occupational and environmental risks to reproduction in
females: Specific exposures and impact", section on 'Air pollution'.)
Environmental tobacco smoke may also have an adverse effect on the fetus, but data are limited. The effects of passive and active smoking on pregnancy are discussed in
detail separately. (See "Secondhand smoke exposure: Effects in adults" and "Cigarette and tobacco products in pregnancy: Impact on pregnancy and the neonate", section
on 'Effects of secondhand smoke'.)
● Air travel – Frequent business-related air travel is common and generally safe during pregnancy. Issues related to air travel are discussed separately. (See "Prenatal care:
Patient education, health promotion, and safety of commonly used drugs", section on 'Airline travel'.)
● Cosmetics – Workers in hair and nail salons are potentially exposed to hundreds of chemicals. There is no strong evidence of teratogenic effects, but it is prudent for these
workers to wear gloves when possible and attempt to work in well-ventilated areas since data are limited [74-80]. Information on Nail technicians' health and workplace
exposure control is available from the NIOSH.
LEGAL ISSUES
Summary — Women in the workplace and their clinicians should understand the rights of pregnant women in the workplace, familiarize themselves with local and national laws
about maternity leave, review the duration of and benefits granted during maternity leave, and understand expectations about their return to the workplace. Women who have
concerns about treatment during pregnancy, including potential job discrimination, denial of accommodations, need for extended medical leave, or other complex employment
questions arise, are advised to consult legal services [81].
Legal and regulatory issues vary among countries and between states in the United States. A synopsis of laws that serve as the basis of the United States federal legal
framework, which applies in all states, is described below. These laws include the Pregnancy Discrimination Act (PDA) of 1978, the Americans with Disabilities Act (ADA) of
1990, and the Family Medical Act (FMLA) of 1993. These and related court rulings clarify legal expectations related to potential discrimination of pregnant women, their
protection related to any occupation related disability, and employer provided benefits to which they are entitled.
Workplace discrimination — The PDA of 1978 amended Title VII of the Civil Rights Act of 1964 to prohibit sex discrimination on the basis of pregnancy, childbirth, or related
medical conditions. This act requires employers with 15 or more employees to offer medical disability benefits for pregnancy-related disabilities just like all other temporary
disabilities under any health, disability, insurance or sick leave plan [82]. Pregnant workers must be provided the same insurance benefits, accommodations, sick leave, seniority
credits, and reinstatement privileges awarded workers disabled by other causes. In March 2015, the Supreme Court of the United States held that a pregnant employee can
make a prima facie case of discrimination by demonstrating that "she belongs to the protected class, that she sought accommodation, that the employer did not accommodate
her." Such circumstances may merit a summary judgement standard "by providing evidence that the employer accommodates a large percentage of nonpregnant workers while
failing to accommodate a large percentage of pregnant workers."
If an employer requires employees to obtain a clinician's note when taking sick leaves and collecting benefits, the same rule can be applied to pregnant employees.
In the United States, federal law prohibits discrimination due to pregnancy, childbirth, or related medical conditions under the PDA and ADA [83,84]. The ADA Amendments Act
(ADAAA) in 2008 directed the Equal Employment Opportunity Commission to modify the degree of limitation defined as a disability replacing "severely or significantly" with
"substantially limits," a more lenient standard. The ADA and ADAAA also apply to employers with 15 or more employees, including state and local governments. Provisions
include:
● Pregnant employees must be allowed to work so long as they can perform their jobs. Women who are pregnant or affected by related conditions must be treated in the same
manner as other applicants or employees with similar abilities or limitations.
● Accommodations must be provided for pregnant women, regardless of the severity of their pregnancy-related work limitations, if similar accommodations are provided to
other employees with similar abilities or inabilities to work. For example, if an employer provides alternative work for nonpregnant employees who are unable to perform their
usual lifting duties or heavy physical labor because of back issues, the employer must make similar arrangements for a pregnant employee.
● Employers cannot require a pregnant employee to take leave due to the pregnancy so long as she can perform her job. If an employee takes leave for a pregnancy-related
condition and recovers, an employer cannot require her to remain on leave.
● Employers may not refuse to employ a woman because of her pregnancy, a pregnancy-related condition, or the prejudices of coworkers or customers.
In 1991, the Supreme Court ruled that a rigid policy that banned women of reproductive age from certain jobs discriminated against women on the basis of their sex. Although
several toxic substances found in the workplace also could harm men of reproductive age, men were not banned from jobs on that basis. Therefore, it is illegal for an employer to
ban a woman from certain jobs because she might become pregnant while working there.
Family Medical Leave Act — In the United States, the FMLA enacted in 1993 "entitles eligible employees of covered employers to take unpaid, job-protected leave for specified
family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave" [85]. The benefit
applies to workers in same-sex relationships as well as heterosexual couples.
To be eligible for FMLA coverage, an employee must have worked more than half-time (1250 hours) for at least one year at a company where more than 50 employees work at
that location or within 75 miles [85]. Based on this requirement, more than 40 percent of workers are not eligible [86]. However, some state laws expand coverage to employees
of employers with fewer workers, including Vermont (10 employees), Maine and Maryland (20), the District of Columbia (20), Minnesota (21), Oregon (25), and Rhode Island
(public employers, 30; private employers, 50). Washington State requires all employers to provide parental leave.
Eligible employees are entitled to the equivalent of 12 work weeks of (unpaid) leave in a 12-month period [87]. This may be a continuous leave of absence (one block of time,
generally 3+ days); multiple, consecutive continuous leaves between intervals of work; intermittent leave of absence (any regular interval of absences that don't follow a schedule
such as an hour appointment once a month or several days a year); or reduced leave of absence (scheduled, such as when employees can only work four hours a day
maximum, miss every Tuesday/Wednesday, or similar). In cases where both spouses work for the same employer, the combined FMLA leave for an uncomplicated birth is 12
weeks, although individual 12-week leaves may apply in case of a complicating serious condition (maternal or newborn). Leaves may be taken for the following indications [85]:
● The birth and care of a child within one year of birth
● The placement and care of an adopted or foster child within one year of placement
● To care for the employee's spouse, child, or parent who has a serious health condition
● A serious health condition that makes the employee unable to perform the essential functions of his or her job
● Any qualifying need stemming from the fact that the employee's spouse, son, daughter, or parent is a covered military member on "covered active duty"
● Twenty-six workweeks of leave during a single 12-month period to care for a covered service member with a serious injury or illness if the eligible employee is the service
member's spouse, son, daughter, parent, or next of kin (military caregiver leave)
Federal law also states that when the need for leave is foreseeable based on an expected birth or planned treatment, an employee must give at least 30 days' notice of such
leave to the employer. If such notice is not possible, an employee is required to provide notice "as soon as practicable," generally interpreted as verbal notice within one to two
business days.
Maternity leave — The FMLA, similar to the PDA, requires a continuation of benefits during pregnancy-related leave similar to that provided to other disabled employees,
including maintenance of the employee's group health benefits [85]. In the United States, women with greater resources, as reflected in access to paid maternity leave, were
more likely to have insurance coverage continued postpartum, less likely to lose private or public health insurance, and much less likely to become uninsured after giving birth
[88]. (See 'Family Medical Leave Act' above.)
In addition, an employer cannot prohibit an employee from taking less time than the maximum. For example, the employee may choose to work until her delivery and return to
work soon after or she may take leave for an antepartum problem and return to work before delivery if the problem resolves.
Given these issues, women of reproductive age searching for employment often evaluate employer policies on maternity leave as well as policies on issues related to childcare,
such as flexible schedules, part-time work, working from home, leaving early for child-related needs, sick children/snow days, dependent care spending accounts, childcare
assistance, resource and referral programs, etc.
Federal oversight — The Equal Employment Opportunity Commission (EEOC) provides federal oversight of certain employer activities involving discrimination, including those
related to pregnancy [89]. Its Policy guidance related to pregnancy discrimination, issued in 2014, provides an overview. The United States Department of Labor Wage and Hour
Division enforces issues pertaining to the FMLA.
In the United States, pregnancy discrimination remains prevalent and represents a large portion of claims brought against employers by women. During fiscal year 2015, the
EEOC received 3543 complaints about pregnancy discrimination [90]. Almost 31,000 charges of pregnancy discrimination were filed with the EEOC and state-level fair
employment practice agencies during fiscal years 2011 to 2015, of which 31 percent were filed by women alleging they were discharged for becoming pregnant [90,91]. Women
also reported being denied the minor job modifications they needed to continue working while pregnant, (eg, more frequent bathroom breaks or availability of a water bottle).
The EEOC reports that pregnancy-related violations have involve a variety of complaints, including [92]:
● Refusing to hire, failing to promote, demoting, or firing pregnant workers after learning they are pregnant.
● Discharging workers who take medical leave for pregnancy-related conditions (such as a miscarriage).
● Limiting employment opportunities for pregnant women, such as by refusing to hire them, placing them on involuntary leave, refusing to let them continue working beyond a
certain point in the pregnancy, reducing work hours, or limiting work assignments due to employer safety concerns.
● Requiring medical clearances not required of non-pregnant workers.
● Failing to accommodate pregnancy-related work restrictions where similar accommodations are or would be provided to non-pregnant workers.
● Refusing to allow lactating mothers to return to work.
● Retaliating against employees, or those close to pregnant employees, who complained about pregnancy discrimination.
International perspective — Similar patterns have been reported in other countries. As an example, in Australia, the Fair Work Ombudsman reported that in 2013, for the first
time, there were more complaints about pregnancy-related discrimination than complaints from both sexes related to mental or physical disability [93]. In contrast, European
countries generally offer women and families substantially more generous family-related benefits than in the United States (table 3). These include paid, rather than unpaid,
pregnancy-related leave that applies to both men and women. Maternity leave, paid typically at 80 to 100 percent of previous earnings, extends from 14 weeks to a full year
depending on the country. An analysis of birth outcomes reported that mean prenatal maternity leave across 36 countries was six weeks (standard deviation = 2.7; range 2 to 14
weeks) [94].
ROLE OF HEALTH CARE PROVIDER
Workplace accommodations and leave — Clinicians caring for working pregnant women are often asked for advice and documentation for workplace accommodations or
medical leave [95]. The basis for such requests may stem from the nature of the woman's work (eg, extreme physical activity, toxin exposure), from the pregnancy and
pregnancy-related complications (eg, twins, placenta previa), or from non-pregnancy medical morbidities (eg, cardiovascular disease).
● Workplace accommodations – Workplace accommodations are "reasonable adjustments to your duties or work setting to allow you to continue working safely while
pregnant or recovering from pregnancy" [96]. Examples of reasonable adjustments include temporary transfer to a less hazardous or strenuous job, provision of modified
equipment or devices (eg, providing a stool for cash register clerk), more frequent or longer breaks, and working from home (table 4).
● Medical leave – Medical leave is time away from work for the woman who cannot safely perform the essential components of her job because of pregnancy, childbirth, or
related medical conditions [96]. Medical leave typically applies to complications of pregnancy or childbirth. Being pregnant is itself not a disability. Impairments that are
automatically considered disabilities are listed by the United States Social Security Administration.
Issues for consideration — In assessing the need for accommodations or medical leave, the clinician must consider the following issues:
● Nature and perception of risk – While "risk" is defined as the likelihood of occurrence of an adverse event, risk perception includes the person's expectations about the
probability of an event, and the myriad meanings and weights the individual assigns to being at risk [97]. These in turn influence the actions the person takes related to the
risk, including, for a pregnant woman, those related to her work. The prenatal care clinician's understanding of a pregnant woman's perceptions related to occupational risks
is critical to assisting her in choosing an appropriate response to them. The clinician must assess:
• The type of risk and the likelihood that it will affect the woman or her pregnancy.
• The woman's understanding of the concept of risk and perception of the degree of risk involved.
• The timing of the risk (eg, exposures may be of maximum risk during particular developmental intervals, while activity-related risks may increase in magnitude as
pregnancy progresses).
● Laws and regulations – The clinician needs to understand the federal, state, and local laws related to pregnancy accommodations and disability leave.
● Employer- and job-related factors.
• Whether reduction of risk is possible through workplace accommodations (including progressive over time) or requires a leave, and the required duration of such
modification necessary.
• Whether the necessary alteration in work activities involves essential work functions of the woman's job.
• Whether the employer has a light duty program and the employer's history of providing accommodations to other employees, pregnant women, or those with disabilities.
● Psychosocial.
• The availability of resources to the woman to assist in obtaining a satisfactory response from her employer (eg, employer human resources, union, legal, or social
services, etc).
• Whether the woman is currently willing to disclose her pregnancy to her employer.
• The woman's financial resources and employment alternatives both with her current employer and elsewhere.
• Potential risks related to taking a leave (isolation, loss of insurance, family violence) and options to minimize their effects.
Certification and sharing health information — In contrast to Family Medical Leave Act (FMLA) certification, to be protected by the Americans with Disabilities Act (ADA), a
patient must have a specific impairment that "substantially limits one or more major life activities" [83]. The ADA does not list all qualifying impairments.
The FMLA regulations clarify that communication with an employer must comply with the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations. The
FMLA certification may be written to be sufficiently vague so that HIPAA laws are not violated, for instance providing only an estimation of treatment and/or absences which
cannot be reliably linked to specific diagnoses. However, obtaining the patient's consent to disclosure of HIPAA protected information may facilitate planning and discussion of
schedule and accommodations.
When a pregnant woman initially seeks leave for an FMLA-qualifying reason, she must provide sufficient information to make the employer aware of the need for FMLA leave and
the anticipated timing and duration of the leave. However, she does not need to mention FMLA; FMLA designation is at the discretion of the employer. Generally an employer
may retroactively reclassify other leave time (eg, sick time, paid vacation) to be part of an FMLA leave only if they do so within two business days of becoming aware that the
leave qualified as FMLA leave. This may alter the maximum duration of total allowable leave. Depending on the situation, sufficient information may include that the employee is
pregnant or has been hospitalized overnight or that she is unable to perform the functions of the job.
While an employee is not required to give the employer her medical records or sign a release of information, the employer does have the right to request medical certification
containing sufficient medical facts to establish that a serious health condition exists. Such a request for medical certification should occur within five business days of when the
employee gives her notice (or takes an unplanned leave); however, certification may be requested at a later date if the employer has reason to question the appropriateness or
duration of the leave. (See 'Writing a medical certification letter' below.)
Employers may contact an employee's health care provider to authenticate or clarify the medical certification, but only with the employee's consent [98]. This contact should
occur through an employer's human resource professional, leave administrator, or other management official. However, FMLA regulations specify that in no case may the
employee's direct supervisor contact the employee's health care provider. Provision of individually identifiable health information requires the written authorization of the
employee, allowing the health care provider to disclose such information to the employer. Employers may not ask for information beyond that contained on the medical
certification form.
Writing a medical certification letter — Most healthy pregnant women do not meet the definition of disability and thus do not qualify for an alteration in their work status before
the onset of labor. Further, if a clinician writes that a pregnant worker is unable to perform the essential duties of her job, and accommodations cannot be made that do not create
an "undue hardship" for the employer, she could be terminated if she is not eligible for leave or if she uses all her available leave [95].
Common requests for work restrictions and suggested note-writing instructions are presented in the table (table 5 and table 6), and a sample work letter is presented in the form
(form 1). Employers may provide forms for FMLA requests although they may not require that they be used. Federal forms are available (https://www.dol.gov/whd/fmla/), but
employers are required to accept any format that conveys complete and sufficient information.
Prior to composing a medical certification letter requesting an accommodation or leave, the clinician and woman need to discuss [81,95]:
● Is a work restriction really necessary?
● Does the woman's pregnancy-related condition prevent her from safely performing an "essential function" (these include primary duties) of her job?
● Is an accommodation in work duties sufficient to mitigate the risk?
● Does the employer have a light-duty program or policy for employees with temporary incapacity?
● Is the need for accommodation likely to be time-limited, or will it extend to the end of the pregnancy? When will the accommodation need to be initiated?
● Can the accommodation be progressive in scope, including possibly leading up to a leave? If so, what guidance can be given regarding the progressive steps (eg, duration
of standing, limits on weight lifted, total work hours) and the timing of the start of a terminal leave?
● Is the total time of pregnancy-related leave (including postpartum) likely to exceed the 12 weeks (or longer depending on state or city statutes) of job protection provided by
Family Medical Leave Act?
Ascertaining that the woman recognizes the risk and is basing her perceptions related to it on an adequate understanding of the nature and magnitude of the risk, along with
developing an understanding of the values and priorities of the woman, provides the basis for further discussion. (See 'Issues for consideration' above.)
To be of greatest benefit, a medical certification should include [95]:
● The specific pregnancy-related impairment for which the accommodations or leave is requested
● When the condition started and how long it may last, or the date of re-evaluation if duration is uncertain
● Whether the woman will be capable of performing her position's essential functions
● The specific limitations required
● The timing of the initiation and any stepped increase of accommodations
● Suggested accommodations
RESOURCES FOR PATIENTS AND CLINICIANS
● Pregnant@work – A free website from the Center for WorkLife Law, University of California, Hastings College of the Law that provides general information, tools, and
educational materials about accommodating pregnant women at work
● Family Medical Leave Act
● Americans with Disabilities Act
● Pregnancy Discrimination Act
● American College of Obstetricians and Gynecologists provides guidance for ACOG members
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See
"Society guideline links: Prenatal care".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best
for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education
articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Activity during pregnancy (The Basics)")
SUMMARY AND RECOMMENDATIONS
● As the number of women in the workforce has risen, so has the number of women working while pregnant. In addition, women are working later into their pregnancies than
ever before. More women are also returning to work within six months after their first birth than in previous decades (21 versus 73 percent from the early 1960s to the period
2005 to 2007). (See 'Prevalence' above.)
● While many women work while pregnant without any interference from pregnancy-related changes, problems of nausea and vomiting, pain, and fatigue can negatively
impact a woman's work performance. Despite data limitations, working while pregnant generally does not appear to negatively impact maternal or fetal health. However, the
physical demands of the woman's job should be considered on a case-by-case basis, especially in women at higher risk of preterm delivery or who have medical or
obstetrical disorders that are unstable or associated with impaired placental perfusion (eg, preeclampsia, fetal growth restriction). (See 'Impact' above.)
● To date, the available evidence does not justify imposing mandatory restrictions to working hours, shift work, lifting, standing, and physical work during pregnancy.
Challenges to writing such guidelines include the lack of data demonstrating a clear cut-off at which work is detrimental to the health of most women and fetuses as well as
the reality that some women must continue working while pregnant for economic reasons, regardless of medical advice. Any guidelines must also balance the data
suggesting that some level of physical activity while pregnant is healthy. (See 'Work characteristics' above.)
● In the United States, the Occupational Safety and Health Administration (OSHA) sets and enforces standards requiring employers to provide a workplace free from
recognized hazards likely to cause serious physical harm. Every employer is mandated to have a Hazard Communication Safety Data Sheets that contain information on the
chemical properties and health effects of the substances used in the workplace. Exposure to these potential hazards should be minimized or avoided, but do not necessarily
warrant leaving the job. (See 'Obligations of employer' above.)
● Clinicians caring for working pregnant women are often asked for advice and documentation for workplace accommodations or medical leave. (See 'Workplace
accommodations and leave' above.)
• Workplace accommodations are "reasonable adjustments to your duties or work setting to allow you to continue working safely while pregnant or recovering from
pregnancy." (See 'Workplace accommodations and leave' above.)
• Medical leave is time away from work for the woman who cannot safely perform the essential components of her job because of pregnancy, childbirth, or related
medical conditions. Medical leave typically applies to complications of pregnancy or childbirth. Being pregnant is itself not a disability. Impairments that are automatically
considered disabilities are listed by the United States Social Security Administration. (See 'Workplace accommodations and leave' above.)
● Women in the workplace should understand their rights in the workplace, familiarize themselves with local and national laws about maternity leave, review the duration of
and benefits granted during maternity leave, and understand expectations about their return to the workplace. To be protected by the Americans with Disabilities Act (ADA),
a patient must have a specific impairment that "substantially limits one or more major life activities." Most healthy pregnant women do not meet the definition of disability and
thus do not qualify for an alteration in their work status before the onset of labor. (See 'Legal issues' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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v/niosh/docs/2016-106/pdfs/2016-106.pdf (Accessed on October 04, 2016).
64. National Institute for Occupational Safety and Health. Controls for noise exposure, 2014. http://www.cdc.gov/niosh/topics/noisecontrol/default.html (Accessed on October 0
4, 2016).
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66. Noise: a hazard for the fetus and newborn. American Academy of Pediatrics. Committee on Environmental Health. Pediatrics 1997; 100:724.
67. www.Reprotox.org (Accessed on September 22, 2009).
68. Lalande NM, Hétu R, Lambert J. Is occupational noise exposure during pregnancy a risk factor of damage to the auditory system of the fetus? Am J Ind Med 1986; 10:427.
69. Daniel T, Laciak J. [Clinical observations and experiments concerning the condition of the cochleovestibular apparatus of subjects exposed to noise in fetal life]. Rev
Laryngol Otol Rhinol (Bord) 1982; 103:313.
70. Nurminen T, Kurppa K. Occupational noise exposure and course of pregnancy. Scand J Work Environ Health 1989; 15:117.
71. Selander J, Albin M, Rosenhall U, et al. Maternal Occupational Exposure to Noise during Pregnancy and Hearing Dysfunction in Children: A Nationwide Prospective Cohort
Study in Sweden. Environ Health Perspect 2016; 124:855.
72. Gerhardt KJ, Pierson LL, Huang X, et al. Effects of intense noise exposure on fetal sheep auditory brain stem response and inner ear histology. Ear Hear 1999; 20:21.
73. Gerhardt KJ, Abrams RM. Fetal exposures to sound and vibroacoustic stimulation. J Perinatol 2000; 20:S21.
74. Blackmore-Prince C, Harlow SD, Gargiullo P, et al. Chemical hair treatments and adverse pregnancy outcome among Black women in central North Carolina. Am J
Epidemiol 1999; 149:712.
75. Burnett C, Goldenthal EI, Harris SB, et al. Teratology and percutaneous toxicity studies on hair dyes. J Toxicol Environ Health 1976; 1:1027.
76. Holly EA, Bracci PM, Hong MK, et al. West Coast study of childhood brain tumours and maternal use of hair-colouring products. Paediatr Perinat Epidemiol 2002; 16:226.
77. Gallicchio L, Miller S, Greene T, et al. Cosmetologists and reproductive outcomes. Obstet Gynecol 2009; 113:1018.
78. Kersemaekers WM, Roeleveld N, Zielhuis GA. Reproductive disorders due to chemical exposure among hairdressers. Scand J Work Environ Health 1995; 21:325.
79. Efird JT, Holly EA, Cordier S, et al. Beauty product-related exposures and childhood brain tumors in seven countries: results from the SEARCH International Brain Tumor
Study. J Neurooncol 2005; 72:133.
80. McCall EE, Olshan AF, Daniels JL. Maternal hair dye use and risk of neuroblastoma in offspring. Cancer Causes Control 2005; 16:743.
81. ACOG Committee Opinion No. 733: Employment Considerations During Pregnancy and the Postpartum Period. Obstet Gynecol 2018; 131:e115.
82. US Equal Employment Opportunity Commission. Pregnancy discrimination. https://www.eeoc.gov/eeoc/publications/fs-preg.cfm (Accessed on October 10, 2016).
83. United States Department of Justice, Civil Rights Division. Americans with Disabilities Act: Information and technical assistance. https://www.ada.gov/ada_intro.htm (Access
ed on October 10, 2016).
84. https://www.eeoc.gov/eeoc/history/35th/thelaw/pregnancy_discrimination-1978.html (Accessed on October 12, 2016).
85. United States Department of Labor, Wage and Hour Division. Family Medical Leave Act. https://www.dol.gov/whd/fmla/ (Accessed on October 09, 2016).
86. Mayer G. The Family and Medical Leave Act (FMLA): Policy Issues, Library of Congress, Washington, DC 2013.
87. https://www.dol.gov/whd/regs/compliance/whdfs28l.pdf (Accessed on December 02, 2016).
88. Jou J, Kozhimannil KB, Blewett LA, et al. Workplace Accommodations for Pregnant Employees: Associations With Women's Access to Health Insurance Coverage After
Childbirth. J Occup Environ Med 2016; 58:561.
89. https://www.eeoc.gov/laws/types/pregnancy.cfm (Accessed on December 02, 2016).
90. https://www.eeoc.gov/eeoc/statistics/enforcement/pregnancy_new.cfm (Accessed on December 02, 2016).
91. https://www.eeoc.gov/eeoc/statistics/enforcement/pregnancy.cfm. (Accessed on December 02, 2016).
92. Equal Employment Opportunity Commission Office of Legal Counsel. EEOC enforcement guidance on pregnancy discrimination and related issues, 2015. https://www.eeoc
.gov/laws/guidance/upload/pregnancy_guidance.pdf (Accessed on December 06, 2016).
93. https://www.fairwork.gov.au/ (Accessed on October 12, 2016).
94. Kwegyir-Afful E, Adu G, Spelten ER, et al. Maternity leave duration and adverse pregnancy outcomes: An international country-level comparison. Scand J Public Health
2018; 46:798.
95. Jackson RA, Gardner S, Torres LN, et al. My Obstetrician Got Me Fired: How Work Notes Can Harm Pregnant Patients and What to Do About It. Obstet Gynecol 2015;
126:250.
96. American College of Obstetricians and Gynecologists. Patient brochure: Pregnant and working: What you need to know, 2016. https://www.acog.org/-/media/Districts/Distric
t-IX/MembersOnly/PatientBrochure.pdf?dmc=1&ts=20161005T1353143834 (Accessed on October 05, 2016).
97. Bayrampour H, Heaman M, Duncan KA, Tough S. Predictors of perception of pregnancy risk among nulliparous women. J Obstet Gynecol Neonatal Nurs 2013; 42:416.
98. Department of Labor. Family Medical Leave Act regulations. The medical certification and verification process, 2007. https://www.dol.gov/whd/FMLA2007Report/Chapter6.p
df (Accessed on December 06, 2016).
Topic 439 Version 29.0
GRAPHICS
Chemical and physical agents that are reproductive hazards for women in the workplace
Agent Observed effects Potentially exposed workers
Cancer treatment drugs (eg., Infertility, miscarriage, birth defects, low birth weight Health care workers, pharmacists
methotrexate)
Certain ethylene glycol ethers such as: Miscarriage Electronic and semiconductor workers
2-ethoxyethanol (2EE) and
2-methoxyethanol (2ME)
Carbon disulfide (CS2) Menstrual cycle changes Viscose rayon workers
Lead Infertility, miscarriage, low birth weight, developmental Battery makers, solderers, welders, radiator repairers, bridge repainters,
disorders firing range workers, home remodelers
Ionizing radiation (eg., X-rays and Infertility, miscarriage, birth defects, low birth weight, Health care workers, dental personnel, atomic workers
gamma rays) developmental disorders, childhood cancers
Strenuous physical labor (eg., prolonged Miscarriage, premature delivery Many types of workers
standing, heavy lifting)
National Institute for Occupational Safety and Health.
Graphic 64742 Version 2.0
Summary of public health actions based on maternal and infant blood lead levels
BLL: blood lead level.
Reproduced from: Ettinger AS, Gurthrie Wengrovitz A, (Eds). Guidelines for the identification and management of lead exposure in pregnant and lactating women.
National Center for Environmental Health/Agency for Toxic Substances and Disease Registry; Centers for Disease Control and Prevention, Atlanta, GA, 2010. Available
at http://www.cdc.gov/nceh/lead/publications/LeadandPregnancy2010.pdf.
Disease causing agents that are reproductive hazards for women in the workplace
Agent Observed effects Potentially exposed workers Preventative measures
Cytomegalo- virus (CMV) Birth defects, low birth weight, developmental Health care workers, workers in contact with infants Good hygienic practices such as
disorders and children handwashing
Hepatitis B virus Low birth weight Health care workers Vaccination
Human immuno-deficiency virus Low birth weight, childhood cancer Health care workers Practice universal precautions
(HIV)
Human parvovirus B19 Miscarriage Health care workers, workers in contact with infants Good hygienic practices such as
and children handwashing
Rubella (German measles) Birth defects, low birth weight Health care workers, workers in contact with infants Vaccination before pregnancy if no prior
and children immunity
Toxoplasmosis Miscarriage, birth defects, developmental Animal care workers, veterinarians Good hygiene practices such as
disorders handwashing
Varicella-zoster virus (chicken Birth defects, low birth weight Health care workers, workers in contact with infants Vaccination before pregnancy if no prior
pox) and children immunity
National Institute for Occupational Safety and Health.
European paid leave and unemployment benefits
United
Indicator Denmark France Spain Netherlands Sweden Finland Italy Norway Austria Belgium Germany Switzerland
Kingdom
Unemployment benefits
Period
covered
Pay
Maternity-related entitlements
Period
covered
Pay
Paternity-related entitlements
Period
covered
Pay
Parental-related entitlements
Period
covered
Pay
Annual leave
Period
covered
Public
holidays
Sick pay
Period
covered
Pay
Aggregate 7.8 7.2 6.4 6.2 5.9 5.8 5.6 5.6 5.4 5.1 4.7 2.9 2.3
score
Key Most generous Second most generous Third most generous Tied Third least generous Second least generous
Where scores are tied (ie, first equal/second equal/last equal), all tied countries are colored similarly.
Reproduced with permission from: Glassdoor, LlewellynConsulting. Which countries in Europe offer the fairest paid leave and unemployment benefits? Available at:
https://www.glassdoor.com/research/studies/europe-fairest-paid-leave-unemployment-benefits/ (Accessed on December 13, 2016).
Common patient requests for workplace restrictions and potential employment implications
Patient request for work Implications of this type of note on

Language used in note How to improve note
restriction employment
"Can I have a note that states I "Ms. C should not lift more than 10 If lifting more than 10 lbs or bending are essential Lifting is not generally contraindicated in pregnancy.
don't have to lift and bend at lbs or perform activities that functions of her job, there may be no reasonable However, if Ms. C has back pain or pregnancy is
work?" require bending." accommodation that her employer can provide. She exacerbating a back injury, accommodations may be
may be required to take leave starting immediately. appropriate: "Ms. C can continue to perform most
Once her family leave is exhausted, she must return functions of her job while pregnant. She has a
to work or show that she has a disability requiring pregnancy-related back condition that requires her to
accommodation such as finite medical leave. If not, limit lifting to no more than 20 pounds twice per
she can be terminated. hour."
"I need to go on leave because I "Ms. A needs to be able to check This note lacks reference to the patient's medical Explain the implications of going on leave early in
can't check my sugars at work." her blood glucose at work." condition (GDM) and needs to be more specific. pregnancy to the patient, and suggest that
accommodations will likely allow her to continue
working: "Ms. A has a pregnancy-related condition
called gestational diabetes that requires her to
monitor her blood glucose level with a simple test and
to eat small snacks every two to three hours. She will
need a private space in which to check her glucose."
"My work is too stressful, and I'm "Ms. B needs to be kept in a Working in a stress-filled environment may be an Given that there is no pregnancy-related impairment,
worried it is harming my stress-free environment during essential function of her job (eg, she may be an it is not recommended to request accommodations.
pregnancy." this pregnancy." attorney, a customer service representative, or If, however, a mental health diagnosis exists,
clinician). Further, removing stress is not a accommodations can be requested.
"reasonable" accommodation. Finally, no pregnancy-
related impairment has been identified.
"I'm too tired to work full-time." "Ms. D must have reduced work While some employers may be able to offer part-time Confirm fatigue is severe enough to significantly limit
hours during this pregnancy." work, others will count this toward her leave thereby a major life activity. Modest modifications may be
reducing the total leave available for delivery and sufficient: "Ms. D has clinically significant fatigue
post-partum. Intermittent leave may be a reasonable related to her pregnancy. She can continue to work
accommodation under the ADA. with >50% of her time at work spent seated and 15-
minute breaks every 4 hours."
ADA: Americans with Disabilities Act.
From: Jackson RA, Gardner S, Torres LN, et al. My obstetrician got me fired: How work notes can harm pregnant patients and what to do about it. Obstet Gynecol 2015; 126:250. DOI:
10.1097/AOG.0000000000000971. Copyright © 2015 American College of Obstetricians and Gynecologists. Reproduced with permission from Lippincott Williams & Wilkins. Unauthorized
reproduction of this material is prohibited.
Common pregnancy-related impairments and possible workplace accommodations
Condition Limitation Reasonable accommodations*
Back pain Prolonged or repetitive lifting, Use of a heating pad, sitting instead of standing, lifting assistance or limitations, assistive equipment to lift, or
bending, or sitting modification of the duties of the job, such as temporary light duty
Venous thrombosis Prolonged sedentary activity Modification of work station, breaks for exercise, private area in which to administer injections
Carpal tunnel syndrome Repetitive tasks using hands Occasional breaks from manual tasks or typing, specialized programs that allow for dictation instead of typing,
modification of work station to provide wrist support while typing
Chronic migraines Exposure to bright lights or loud Change lighting in the work area, limit exposure to noise and fragrances, change schedule such as flexible
environments schedule or telework
Dependent edema Prolonged standing Stool or chair to sit on while working, more frequent rest breaks, modification of footwear requirements
Dyspnea Ability to perform strenuous Stool or chair to sit on while working, more frequent rest breaks
activities
Fatigue Ability to perform strenuous Light duty to avoid strenuous activity, flexible or reduced hours, exemption from mandatory overtime,
activities or to work long hours intermittent leave
Gestational diabetes Ability to work prolonged periods Permission to take more frequent bathroom breaks, permission to eat small snacks, a private area for testing
without breaks and snacks blood glucose, time off for medical appointments
Hyperemesis gravidarum, Ability to work prolonged periods Permission to take more frequent bathroom breaks, permission to eat small snacks during work hours,
nausea/vomiting without bathroom breaks and modified schedules including working from home
snacks
Hypertension Strenuous or prolonged physical Stool or chair for employee to sit on while working, limit lifting and bending requirements, work from home
activity while on bed rest
Urinary tract infections Ability to work prolonged periods Water bottle at work station, more frequent bathroom breaks
without drinking or using the
restroom
* The appropriate accommodation in each case will vary depending upon the woman's condition and her job. Refer to: Job Accommodation Network, www.askjan.org.
From: Jackson RA, Gardner S, Torres LN, et al. My obstetrician got me fired: How work notes can harm pregnant patients and what to do about it. Obstet Gynecol 2015; 126:250. DOI:
10.1097/AOG.0000000000000971. Copyright © 2015 American College of Obstetricians and Gynecologists. Reproduced with permission from Lippincott Williams & Wilkins. Unauthorized
reproduction of this material is prohibited.
Selected note-writing instructions for work accommodations
Guideline Model note language To avoid
State patient is pregnant and needs an accommodation. "Patient is affected by pregnancy, childbirth, or lactation It is the patient's decision if she does not want to reveal her
(whichever relevant) and requires an accommodation." pregnancy, but she may be less likely to receive an
accommodation.
Identify patient's pregnancy-related medical conditions (eg, Depends on the state. In some states, disclosure of specific If guidelines at www.pregnantatwork.org/healthcare-
severe back pain, gestational diabetes, etc), if any. medical condition is not required. In some states, professionals/ say that the disclosure of medical condition is
identifying specific condition and other medical details may not necessary in your state, maintain your patient's privacy.
be necessary to receive an accommodation. Visit
www.pregnantatwork.org/healthcare-professionals/ for
state-by-state guidelines.
Specifically and precisely identify work limitations that are Patient "is unable to stand for more than one hour without Avoid vague statements, such as "needs light duty" or "no
recommended medically. 15 minutes of sitting," "may not climb ladders," or "must physical activity." Also avoid imposing restrictions that are
take 15-minute breaks every three hours to eat a snack." not medically indicated, because the patient could be sent
out on unpaid leave or terminated if accommodation is not
possible.
Affirmatively state that the patient can continue working. "Patient is able to continue working with a reasonable This does not apply in situations in which the patient
accommodation." requires leave, for example to recover after cesarean
delivery.
Recommend reasonable accommodations based on your "I recommend that my patient be given a stool to sit on Avoid recommending specific accommodations without
knowledge of the workplace. while checking out customers at the cash register." talking to your patient about what is possible in her
workplace.
State expected duration of the accommodation. "Patient's medical limitation and need for accommodation Do not fail to include end date just because end date is
began on [DATE]. I anticipate the patient will need an uncertain. It can be changed in the future if necessary.
accommodation until [DATE]."
Reproduced from: Karkowsky CE, Morris L. Pregnant at work: Time for prenatal care providers to act. Am J Obstet Gynecol 2016; 215:306.e1. Table used with the permission of Elsevier Inc.
All rights reserved.
Sample work modification letter for pregnant employees
From: Jackson RA, Gardner S, Torres LN, et al. My obstetrician got me fired: How work notes can harm pregnant
patients and what to do about it. Obstet Gynecol 2015; 126:250. DOI: 10.1097/AOG.0000000000000971.
Copyright © 2015 American College of Obstetricians and Gynecologists. Reproduced with permission from
Lippincott Williams & Wilkins. Unauthorized reproduction of this material is prohibited.

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Topics related to occupational risks and exposure are presented separately.

● (See "Overview of occupational and environmental risks to reproduction in females".)

● (See "Overview of occupational and environmental health".)

● (See "Overview of occupational and environmental risks to reproduction in females".)

● (See "Overview of occupational and environmental health".)

● Dyes used in manufacturing

● Pesticides and herbicides

● Products used in rubber, plastics, and textile manufacturing

Additional information on potential teratogens can be found at the following resources:

● National Library of Medicine (NLM)

Columbia Hospital for Women Medical Center

● Teratogen Information System (TERIS)

● Pregnancy Exposure Registries

● MotherToBaby, Organization of Teratology Information Specialists (OTIS)

● The Hospital for Sick Children

● Pediatric Environmental Health Specialty Units (PEHSU)

• (See "Adult occupational lead poisoning", section on 'Pregnancy and breastfeeding'.)

condition and recovers, an employer cannot require her to remain on leave.

● The birth and care of a child within one year of birth

● Requiring medical clearances not required of non-pregnant workers.

● Refusing to allow lactating mothers to return to work.

ROLE OF HEALTH CARE PROVIDER

● Employer- and job-related factors.

● Is a work restriction really necessary?

● Is an accommodation in work duties sufficient to mitigate the risk?

To be of greatest benefit, a medical certification should include [95]:

● The specific limitations required

● The timing of the initiation and any stepped increase of accommodations

RESOURCES FOR PATIENTS AND CLINICIANS

● Family Medical Leave Act

● Americans with Disabilities Act

● Pregnancy Discrimination Act

SUMMARY AND RECOMMENDATIONS

warrant leaving the job. (See 'Obligations of employer' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 439 Version 29.0

Agent Observed effects Potentially exposed workers

Carbon disulfide (CS2) Menstrual cycle changes Viscose rayon workers

National Institute for Occupational Safety and Health.

Graphic 64742 Version 2.0

BLL: blood lead level.

Graphic 75815 Version 4.0

Agent Observed effects Potentially exposed workers Preventative measures

Hepatitis B virus Low birth weight Health care workers Vaccination

National Institute for Occupational Safety and Health.

Graphic 65355 Version 2.0

European paid leave and unemployment benefits

Graphic 111124 Version 1.0

Patient request for work Implications of this type of note on

ADA: Americans with Disabilities Act.

Graphic 110110 Version 1.0

Common pregnancy-related impairments and possible workplace accommodations

Condition Limitation Reasonable accommodations*

Graphic 110109 Version 1.0

Selected note-writing instructions for work accommodations

Guideline Model note language To avoid

Graphic 110115 Version 1.0

Sample work modification letter for pregnant employees

Graphic 110112 Version 1.0

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