Working during Pregnancy

1. Working during Pregnancy Dr Sally Coomber MRCGP FFOM FRCP Consultant Occupational Physician The Ipswich Hospital NHS Trust Trent Occupational Medicine Annual Symposium University of Nottingham 18 October 2012

2. Overview Applying the biopsychosocial model to three trimesters of pregnancy Work and what can go wrong clinically Consequences of low birthweight babies

3. Legal framework Model risk assessment: http://www.sohas.co.uk/publications/publication18.pdf

4. Risk assessment references to risk, in relation to risk from any infectious or contagious disease, are references to a level of risk at work which is in addition to the level to which a new or expectant mother may be expected to be exposed outside the workplace ..the work is of a kind which could involve risk, by reason of her condition, to the health and safety of a new or expectant mother, or to that of her baby, from any process or working conditions or physical, biological or chemical agents The Approved Code of Practice explains: Where the risk assessment identifies risks to new and expectant mothers and these risks cannot be avoided by the preventive and protective measures taken by an employer, the employer will need to... Where, in the case of an individual employee, the taking of any other action the employer is required to take under the relevant statutory provisions would not avoid the risk...the employer shall, if it is reasonable to do so and would avoid such risks, alter her working conditions or hours of work

5. Working during pregnancy: BPS model

6. Conception

7. 8 weeks

8. 12 weeks

9. 1st trimester

10. ‘Psychological tasks of pregnancy’ • Accepting the reality of pregnancy • Facing the consequences of being pregnant • Coping with physical changes • Coping with uncertainty, unpredictability • Coping with change in role and relationships • Managing unexpected events and ‘minor disorders of pregnancy’ Psychological Challenges in Obs & Gynae. The clinical management. Cockburn J, Pawson ME. 2007. Springer-Verlag London.

11. First trimester • Biological: embryo implantation, organ formation, physiological changes; risk of early miscarriage • Psychological: confirmation of pregnancy, change nutrition/alcohol; mood changes; EDD established; denial?; ‘fat’? • Social: booking of care; timing of declaration of pregnancy; expectations of behaviour; ‘precious vessel’ status of primagravida?

12. First trimester work and birthweight • Am J Public Health 2009; 99(8): 1409-16 • Prospective cohort in Amsterdam • N=8266 pregnant women • Outcome measures: birthweight, SGA* baby • High job strain: mean b’wt decrease 72g • Work week >32 hours: mean b’wt decrease 43g • Both factors: mean b’wt reduction 150g and SGA baby OR=2.0 (CI 1.2, 3.2) *SGA = small for gestational age

13. Miscarriage • Pregnancy loss before 24 weeks • 1:5 risk of miscarriage • 1:100 risk recurrent (three +) miscarriages • First pregnancy miscarriage: increased risk of complications next pregnancy • RCOG no guidance on work factors Ref: RCOG news 2008

14. Miscarriage and work (1) • Heavy lifting >15x /day: doubled relative risk • Lifting >9kg: RR 1.75 • Frequent lifting >15lbs: no significant effect • Physical effort: RR 1.87 • Standing >8hours/day: RR 1.32; OR 1.6 • Working >40 hr/week: no significant effect Ref: Physical and shift work in pregnancy, NHS Plus 2009

15. Miscarriage and work (2) • >2 previous miscarriages, plus standing >7 hours/day: OR 4.32 • If miscarriage: ‘increased’ rate of >40 hrs/day in previous pregnancies • Night work & 2 shift schedules, for first pregnancy: RR 4.69 • Rotating shifts: ‘increased’ risk • Fixed evening shift: OR 4.17

16. 16 weeks

17. 24 weeks

18. 2nd trimester

19. Second trimester Biological: fetus development; fetal movements felt; sleep-wake cycle; maternal BP may fall, sensation of SOB Psychological: obviously pregnant; ‘blooming’; energetic; bonding Social: antenatal checks; Down’s syndrome screening; anomaly scan; maternity leave plans; expected to work normally? maternity uniform? PPE?

20. ‘Work’ and hypertension • 2001 study in Cork n=933 primagravidas, no work classification. Mid-term BP monitoring • The women who were working had the highest blood pressure readings • Older women also tended to have higher BPs • Women in employment were almost five times as likely to develop pre-eclampsia • There were no differences in length of pregnancy, birthweight, or method of delivery Ref:Journal of Epidemiology and Community Health 2002

23. ‘Minor disorders of pregnancy’ • Relevant to work: • Frequency of PU • Carpal tunnel syndrome • Sleeplessness • Tired, SOB • Softened ligaments • Pubic symphysis dysfunction • Low back pain • Ankle oedema

24. Third trimester • Biological: fetalgrowth ++; fetus viable for premature birth; placental blood flow increases++, risks of pre-term labour, stillbirth • Psychological: preparation for birth; anxiety; impact of tiredness; poor sleep • Social: mat leave, air travel restriction; help from colleagues; multip. expected to continue household work? domestic violence?

25. Working in later pregnancy • “What should I do if my job involves physical activities? • It is probably advisable to reduce these activities, particularly in the late stages of pregnancy: • lifting heavy loads • hard physical work • prolonged standing – for longer than three • hours at a time • long working hours – working longer than • around 40 hours per week”

26. Low birthweight, preterm delivery and work • High physical work demands: low birthweight <2500g • Working >40 hours/week, Shiftwork: birthweight <3000g • Temporary work contract and preterm birth (?indirect measure of stress and anxiety) • If 2 or more out of 4 risk factors: low birthweight OR 4.65; preterm delivery OR 5.18

27. Stress and Pregnancy • Makes intuitive sense • Evidence from studies vary • No consistent definition of ‘stress’ • The most common stressogenic events reported by women who had obstetric complications were: • high anxiety about the health status of the fetus • death of a loved one • arguments with parents or spouse • a sharp decline in income • job-related problems of spouse”

28. Stillbirth, perinataland neonatal death • UK rates falling since 2000 • 2009 CMACE report*: • Stillbirth 5.2 per 1000 total births • Perinatal mortality 7.6 per 1000 total births • 10% had BMI of 35 or over • Neonatal mortality 3.2 per 1000 live births • 2008 Danish study: • high psychological stress increased stillbirth rate by 80% *Centre for Maternal and Child Enquiries

29. The perils of googling ‘working during pregnancy’....

30. Why does birthweight matter? Impact on childhood development

31. Millenium Cohort Study 19,000 children born in UK 2000-2001 Four MCS surveys at 9 months, 3, 5 and 7 years so far

32. Selected predictive factors for children’s learning & development Odds ratio (adjusted) for poor learning & development

33. Worklessness, poverty and childhood development

35. Worklessness and Poverty:

38. ‘High Risk Pregnancy’: • High risk mother +/- high risk fetus • Maybe less likely to be working at all? • Do OH communicate with obstetric team or vice versa?

40. Summary • Risk assessment requirements • BPS model applied in each trimester • Work and what can go wrong • Why work and low birthweight matter • Obstetricians and pregnant doctors