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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: Sep 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 "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 are any adverse effects of maternal employment on child development, these effects are likely to be small [21-23].

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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".)

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● (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 "Overview of occupational and environmental risks to reproduction in females", 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:

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• (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 "Overview of
occupational and environmental risks to reproduction in females", 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 "Overview of occupational and environmental risks to reproduction in
females", section on 'Endocrine disruptors' 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. (See "Overview of occupational and environmental
risks to reproduction in females", section on 'Antineoplastic drugs and sterilizing agents' and "Overview of occupational and environmental risks to reproduction in
females", section on 'Inhalational anesthetics'.)

● 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 "Overview of occupational and
environmental risks to reproduction in females", section on 'Nonionizing radiation'.)

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

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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 'Postarrest 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 "Overview of
occupational and environmental risks to reproduction in females", section on 'Airborne pollutants'.)

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.

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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.

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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?

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● 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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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
disorders repainters, 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.

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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.

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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 Low birth weight, childhood cancer Health care workers Practice universal precautions
virus (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.

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European paid leave and unemployment benefits

United
Indicator Denmark France Spain Netherlands Sweden Finland Italy Norway Austria Belgium Germany Switzerl
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 generou

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).

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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
don't have to lift and bend at
work?"
"Ms. C should not lift more than
10 lbs or perform activities that
require bending."
If lifting more than 10 lbs or bending are essential
functions of her job, there may be no reasonable
accommodation that her employer can provide. She
may be required to take leave starting immediately.
Once her family leave is exhausted, she must return
to work or show that she has a disability requiring
accommodation such as finite medical leave. If not,
she can be terminated.
Lifting is not generally contraindicated in pregnancy.
However, if Ms. C has back pain or pregnancy is
exacerbating a back injury, accommodations may be
appropriate: "Ms. C can continue to perform most
functions of her job while pregnant. She has a
pregnancy-related back condition that requires her
to limit lifting to no more than 20 pounds twice per
hour."

"I need to go on leave because I
can't check my sugars at work."
"Ms. A needs to be able to check
her blood glucose at work."
This note lacks reference to the patient's medical
condition (GDM) and needs to be more specific.
Explain the implications of going on leave early in
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
worried it is harming my
pregnancy."
"Ms. B needs to be kept in a
stress-free environment during
this pregnancy."
Working in a stress-filled environment may be an
essential function of her job (eg, she may be an
attorney, a customer service representative, or
clinician). Further, removing stress is not a
"reasonable" accommodation. Finally, no pregnancy-
related impairment has been identified.
Given that there is no pregnancy-related
impairment, it is not recommended to request
accommodations. If, however, a mental health
diagnosis exists, accommodations can be requested.

"I'm too tired to work full-time."
"Ms. D must have reduced work
hours during this pregnancy."
While some employers may be able to offer part-
time work, others will count this toward her leave
thereby reducing the total leave available for
delivery and post-partum. Intermittent leave may be
a reasonable accommodation under the ADA.
Confirm fatigue is severe enough to significantly
limit a major life activity. Modest modifications may
be sufficient: "Ms. D has clinically significant fatigue
related to her pregnancy. She can continue to work
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.

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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,
bending, or sitting or 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
without breaks and snacks testing 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.

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Selected note-writing instructions for work accommodations
Guideline
State patient is pregnant and needs an accommodation.
Identify patient's pregnancy-related medical conditions
(eg, severe back pain, gestational diabetes, etc), if any.
Specifically and precisely identify work limitations that are
recommended medically.
Affirmatively state that the patient can continue working.
Recommend reasonable accommodations based on your
knowledge of the workplace.
State expected duration of the accommodation.
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.
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Working during pregnancy - UpToDate
Model note language
"Patient is affected by pregnancy, childbirth, or lactation
(whichever relevant) and requires an accommodation."
Depends on the state. In some states, disclosure of
specific medical condition is not required. In some states,
identifying specific condition and other medical details may
be necessary to receive an accommodation. Visit
www.pregnantatwork.org/healthcare-professionals/ for
state-by-state guidelines.
Patient "is unable to stand for more than one hour without
15 minutes of sitting," "may not climb ladders," or "must
take 15-minute breaks every three hours to eat a snack."
"Patient is able to continue working with a reasonable
accommodation."
"I recommend that my patient be given a stool to sit on
while checking out customers at the cash register."
"Patient's medical limitation and need for accommodation
began on [DATE]. I anticipate the patient will need an
accommodation until [DATE]."
To avoid
It is the patient's decision if she does not want to reveal
her pregnancy, but she may be less likely to receive an
accommodation.
If guidelines at www.pregnantatwork.org/healthcare-
professionals/ say that the disclosure of medical condition
is not necessary in your state, maintain your patient's
privacy.
Avoid vague statements, such as "needs light duty" or "no
physical activity." Also avoid imposing restrictions that are
not medically indicated, because the patient could be sent
out on unpaid leave or terminated if accommodation is not
possible.
This does not apply in situations in which the patient
requires leave, for example to recover after cesarean
delivery.
Avoid recommending specific accommodations without
talking to your patient about what is possible in her
workplace.
Do not fail to include end date just because end date is
uncertain. It can be changed in the future if necessary.
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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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