Occupational Medicine 2012;62:88–97

doi:10.1093/occmed/kqr198

IN-DEPTH REVIEW
...............................................................................................................................................................................................

Pregnancy in the workplace

H. M. Salihu1,2, J. Myers3 and E. M. August3
1
Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, 13201 Bruce B. Downs
Boulevard, MDC 56, Tampa, FL 33612, USA, 2Occupational Medicine Residency Program, College of Medicine, University
of South Florida, 13201 Bruce B. Downs Boulevard, MDC 56, Tampa, FL 33612, USA, 3Department of Community and
Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Boulevard, MDC 56, Tampa,
FL 33612, USA.
Correspondence to: H. M. Salihu, Department of Epidemiology and Biostatistics, College of Public Health, 13201 Bruce B. Downs

Downloaded from https://academic.oup.com/occmed/article/62/2/88/1480061 by guest on 30 May 2022

Boulevard, Tampa, FL 33612, USA. Tel: 11 813 396 9578; fax: 11 813 974 4719; e-mail: hsalihu@health.usf.edu
...................................................................................................................................................................................

Background Women constitute a large percentage of the workforce in industrialized countries. As a result, address-
ing pregnancy-related health issues in the workplace is important in order to formulate appropriate
strategies to promote and protect maternal and infant health.
...................................................................................................................................................................................

Aims To explore issues affecting pregnant women in the workplace.

...................................................................................................................................................................................
Methods A systematic literature review was conducted using Boolean combinations of the terms ‘pregnant
women’, ‘workplace’ and ‘employment’ for publications from January 1990 to November 2010. Stud-
ies that explicitly explored pregnancy in the workplace within the UK, USA, Canada or the European
Union were included.
...................................................................................................................................................................................

Results Pregnancy discrimination was found to be prevalent and represented a large portion of claims brought
against employers by women. The relationship between environmental risks and exposures at work
with foetal outcomes was inconclusive. In general, standard working conditions presented little hazard
to infant health; however, pregnancy could significantly impact a mother’s psychosocial well-being in
the workplace.
...................................................................................................................................................................................

Conclusions Core recommendations to improve maternal and infant health outcomes and improve workplace con-
ditions for women include: (i) shifting organizational culture to support women in pregnancy; (ii)
conducting early screening of occupational risk during the preconception period and (iii) monitoring
manual labour conditions, including workplace environment and job duties.
...................................................................................................................................................................................

Key words Infant health; maternal health; occupational environment; pregnancy.

...................................................................................................................................................................................

Introduction woman may be eligible for temporary job reassignment to

Women constitute almost half of the labour force in the
USA and the European Union (EU) [1,2]. Seventy per
cent of women in the UK [3] and 59% of women in
the USA participate in the labour force [2]. The increase
of women in the workplace has highlighted the need to
develop workplace policies that protect women, especially
during pregnancy. Several laws are now in force to delin-
eate the rights of pregnant women in the workplace within
the USA, Canada, UK and EU.
In the USA, the Pregnancy Discrimination Act estab-
lished that employers who have at least 15 workers are not
allowed to: (i) refuse to hire a woman because of preg-
nancy; (ii) fire or force a woman to leave because she is
pregnant; (iii) take away credit for previous years experi-
ence, accrued retirement benefits or seniority because of
maternity leave or (iv) fire or refuse to hire a woman
because she has an abortion [4]. Additionally, a pregnant
Ó The Author 2012. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
All rights reserved. For Permissions, please email: journals.permissions@oup.com
easier duties if she is unable to perform her current duties
due to pregnancy, similar to temporary reassignment
afforded to those with a temporary disability, such as
a broken arm. The Family and Medical Leave Act of
1993 further established the rights of pregnant workers
by ensuring 12 weeks of unpaid leave for childbearing
without penalty of losing one’s job [5]. These protections
were established to shield pregnant women from discrim-
ination in the workplace.
Outside the USA, laws provide additional financial and
legal protections to pregnant women. Within the Employ-
ment Insurance Act of 1996, the Federal Government of
Canada ensures up to 15 weeks of paid leave at 55% of
one’s standard pay for pregnancy and childbirth [6].
However, this is a minimum and the provinces have elec-
ted to exceed this threshold. In the UK, greater pro-
tections are provided for pregnant women at the
national level through the Social Security Contributions

and Benefits Act of 1992, including nationally funded
maternity pay [7]. Upon the official announcement of
pregnancy to one’s employer, a mandatory job risk assess-
ment is conducted and job reassignment or modification
must be provided if the current work functions would put
the mother or foetus at risk [8]. If reassignment or risk
avoidance is not an option, then the employee must be
suspended at full pay. Women also receive paid time
off for antenatal care at the normal rate of pay. Finally,
protections from termination and discrimination are
applied due to pregnancy. The European Union directive
89/391 was passed in 1992 to standardize maternity rights
for women across member countries of the EU [9].
According to this legislation, pregnant workers must
not be exposed to risks to maternal or foetal health
[10]. This includes chemical and biological exposures
and exemption from night shift work, if there is a medical
directive [10].
Pregnancy presents both employers and employees with
challenges not traditionally present in a male-dominated
workforce. In a recent study conducted by the US Census
Bureau among women who have had at least one preg-
nancy, two-thirds of the participants reported employment
during their first pregnancy, and 80% of those who worked
during pregnancy indicated that they worked up to #1
month until birth [11]. The prevalence of working during
pregnancy highlights the importance of understanding
challenges faced by women during this period and under-
scores the need to determine the most appropriate strat-
egies to support women during pregnancy. This paper
explores issues surrounding pregnant women in the work-
place and suggests potential solutions for adapting the
workplace environment to accommodate a pregnancy.
Methods
A systematic literature review was conducted of peer-
reviewed articles published in the English language from
January 1990 through November 2010. Boolean combi-
nations of the key terms—pregnant women, workplace
and employment—were searched in four databases:
PubMed, CINAHL, PsycInfo and Sociological Abstracts.
We included studies that had the central purpose of
exploring issues regarding pregnancy in the workplace
within the USA, Canada, UK and EU. Articles that only
included employment as a potential cofounder were
excluded. In addition to peer-reviewed literature, govern-
ment reports repeatedly cited in articles were retrieved
and included as they were found to provide rich data
regarding the subject matter.
Articles were reviewed and categorized based on
emergent themes. Overarching themes included legal
issues, physical risks, chemical exposures, biological expo-
sures and psychosocial impacts. An overview of the
dominant issues addressed in the body of the literature
H. M. SALIHU ET AL.: PREGNANCY IN THE WORKPLACE 89
relative to pregnancy and the work environment is
presented in Table 1.
Results
Legal issues
The majority of studies examining legal issues surround-
ing pregnancy in the workplace revolve around the con-
cept of pregnancy discrimination. Despite laws in the
USA, Canada, UK and EU to prohibit pregnancy dis-
crimination, studies suggest that women experience
Downloaded from https://academic.oup.com/occmed/article/62/2/88/1480061 by guest on 30 May 2022
a large amount of discrimination, both formally and in-
formally, due to their pregnant state. In a study conducted
by the UK’s Equal Opportunities Commission in 2005,
half of pregnant women reported some form of disadvan-
tage due to pregnancy-related issues [12]. Similarly,
the US Equal Employment Opportunity Commission
reported a 65% increase in pregnancy-related complaints
between 1992 and 2007, which was higher than both
sexual discrimination and sexual harassment reports dur-
ing this period [13]. However, it should be noted that
minimal research has explored the legal issues regarding
pregnancy in the workplace and is mostly limited to
government commissioned reports and those produced
by non-governmental organizations.
Hiring of pregnant women is another area of concern
that has been legally arbitrated. An investigation into
pregnancy discrimination in the UK suggested blatant
disregard for laws prohibiting recruitment discrimination
on the basis of pregnancy [12]. Various recruitment law
breaches were documented, including reports of newly
hired women who were immediately terminated upon
the employers’ discovery of the pregnancy and the prefer-
ence to avoid hiring women of childbearing age. A survey
of employers suggested that pregnant women were seen as
a liability in the workforce that causes undue stress to the
employer [12]. University students also demonstrated
a general bias against employing pregnant women when
examining interview candidates [14]. Studies also suggest
that individuals tend to perceive pregnant women as less
driven and incompetent [12]. These characteristics were
found to influence repeated decisions/inclinations to hire
candidates other than pregnant women, even if the preg-
nant woman in question was better qualified for the role,
based on interviews and resumes [14]. Little formal re-
search has examined the role of pregnancy in termination
and demotion; however, the UK report documents the
presence and prevalence of these issues [12]. The report
found that nearly a quarter of women who filed a preg-
nancy discrimination case to the UK tribunal indicated
that they were terminated within minutes or days of
informing their company about their pregnancy. Women
often were demoted upon their employers learning of
their pregnancy or when returning to work after maternity
90 OCCUPATIONAL MEDICINE

Table 1. Summary of reviewed studies by key workplace exposures for women and feto-infant outcomes

Exposure Feto-infant outcomes

PTB Spontaneous LBW SGA Pre-eclampsia

abortion

Employment Simpson Simpson Seidler Spinillo

(1993) [15]a (1993) [15]a (1999) [45]b (1995) [31]c
Jansen Jansen Jansen
(2010) [34]b (2010) [34]b (2010) [34]b
Physical activity Klebanoff Bryant Niedhammer Klebanoff Spinillo
(1990) [23]b (1991) [32]b (2009) [29]d (1990) [23]b (1995) [31]d
Henrich Hatch
(2003) [28]b (1997) [20]b

Downloaded from https://academic.oup.com/occmed/article/62/2/88/1480061 by guest on 30 May 2022

Niedhammer Niedhammer
(2009) [29]b (2009) [29]b
Hours worked Niedhammer Bryant Niedhammer Hatch
(2009) [29]b (1991) [32]b (2009) [29]b (1997) [20]d
Bonzini
(2009) [22]b
Vrijkotte Niedhammer
(2009) [21]d (2009) [29]b
Fenster Jansen Vrijkotte
(1997) [24]b (2010) [34]d (2009) [21]b
Standing Klebanoff Fenster Klebanoff
(1990) [23]d (1997) [24]a (1990) [23]b
Henriksen
(1995) [25]a
Magann Hatch
(2005) [26]d (1997) [20]b
Bonzini Bonzini
(2009) [22]b (2009) [22]b
Walking Henriksen Bonzini
(1995) [25]a (2009) [22]b
Bonzini
(2009) [22]b
Bending Bonzini Fenster [24]b Bonzini
(2009) [22]d (2009) [22]b
Lifting Bonzini Fenster Hatch
(2009) [22]b (1997) [24]b (1997) [20]b
Bonzini
(2009) [22]b
Stress/job strain Niedhammer Fenster Niedhammer [29]b Niedhammer
(2009) [29]b (1995) [24]a (2009) [29]b
Vrijkotte Vrijkotte
(2009) [21]d (2009) [21]d
Shift work/night shift Bonzini Bryant Niedhammer Bonzini
(2009) [22]b (1991) [32]b (2009) [29]b (2009) [22]b
Niedhammer Fenster Niedhammer
(2009) [29]b (1997) [24]b (2009) [29]b
Organic solvents Testud Ahmed Seidler
(2010) [46]b (2007) [44]b (1999) [45]b
Ahmed
(2007) [44]d
Testud Testud
(2010) [46]b (2010) [46]b

Only first authors listed with year of publication.

a
Inconsistent findings.
b
No association
c
Significant protective factor.
d
Significant risk factor.

leave. In some instances, women were purposefully de-
moted so that employers could avoid paying for maternity
leave benefits associated with Statutory Maternity Pay.
Women also reported loss of bonuses and promotion as
a result of pregnancy.
Physical risks
Environmental risks during pregnancy vary from physical
requirements of the job to characteristics of the physical
environment. Overall, the majority of studies found little
to no negative impact on foetal outcomes due to normal
job-related activities, such as standing, bending, lifting
and long hours although the findings are inconclusive
[15,16]. While the activities alone do not seem to cause
undue burden or cause foetal abnormalities, the extent to
which the work is manual and physically demanding may
have an effect on the pregnant mother.
Falls are the leading cause of occupational injury. Due
to pregnancy-related physiological and anatomical body
changes, the likelihood of falling both at work and at
home is increased and peaks around the 5th–7th month
of pregnancy [17]. Approximately one in four women
report falling during pregnancy, and 23% of these falls
occur at work [17]. Studies indicate that falls among
working pregnant women are more prominent in occupa-
tions already predisposed to falls, such as food service and
teaching and childcare occupations [17]. The causes for
falls vary by occupation, though pregnancy itself does not
seem to be the prominent aetiology. Instead, reported
causes for falls at work are slippery floors, hurried pace
and carrying an object or child. Serious falls at work
are associated with an increased reporting of cuts, broken
bones, emergency room visits, hospital admission, pro-
longed restricted activity and prolonged absence from
work, as opposed to serious falls that occur outside of
work. It is estimated that 0.7% of pregnant women
miss work due to falls at work [17]. Although articles have
documented the harm that falls have on maternal and
foetal outcomes [18,19], studies have not examined
maternal and foetal outcomes resulting from falls among
women at work specifically.
A number of reports have examined the relationship
between the work environment and pregnancy outcomes.
Studies have found no association between standing at
work and low birth weight (LBW) [20,21], small for ges-
tational age (SGA) [21–23], small abdominal circumfer-
ence [22] or small head circumference [22]. However, the
findings regarding spontaneous abortion and preterm
birth (PTB) show some association with standing under
specific circumstances. Although Fenster et al. [24] found
that standing for .7 h a day was not related to spontane-
ous abortion, long periods of standing did increase the
likelihood of spontaneous abortion among women who
had a previous history of spontaneous abortion. Many
studies found no association between standing and
H. M. SALIHU ET AL.: PREGNANCY IN THE WORKPLACE 91
PTB overall [22,23,25,26], whereas others observed
modest increases in the likelihood of PTB when pregnant
mothers who stood at work were compared to those who
did not [23,25,26].
Inconsistencies within studies were common. Magann
et al. [26] found no univariate association between stand-
ing and PTB among low-risk military women; however,
women who stood .4 h a day past 20 weeks gestation saw
a moderate increase (odds ratio 1.69, 95% CI 1.03–2.08)
in the risk of PTB compared to those who stood ,4 h
a day after controlling for hours of lifting and noise expo-
sure. Bonzini et al. [22] reported no association between
standing .4 h a day and PTB in a study of 1327 British
Downloaded from https://academic.oup.com/occmed/article/62/2/88/1480061 by guest on 30 May 2022
women after controlling for primiparity. Though the
investigators observed no association with standing alone,
Henrikson et al. [25] found that the combination of stand-
ing and walking for .5 h a day increased the likelihood of
PTB by 3.3 times compared to women who reported
standing and walking for ,2 h a day. All the aforemen-
tioned studies examining internal inconsistencies with
standing and PTB used a prospective cohort design with
a large sample size (N $ 814). The combined findings
indicate that standing alone at work does not pose a sig-
nificant risk to pregnant women in general.
Bending and lifting are two other work-related expo-
sures examined in the literature. Although trunk bending
.1 h a day was associated with a three times greater likeli-
hood of PTB [22], lifting in general was not shown to have
a significant association with SGA [20,22], preterm deliv-
ery [22,25], small abdominal circumference [22] or small
head circumference [22]. This could be due to low levels
of lifting in traditionally female-oriented occupations or
the potential reassignment to fewer manual labour duties
during pregnancy among women who are otherwise
required to lift heavier objects on a daily basis.
Numerous studies have ascertained that the levels of
manual physical labour in the workplace may influence
pregnancy outcomes, with conflicting findings [27].
Henrich et al. [28] found no association between manual
labour and PTB in their study of German women. Sim-
ilarly, Niedhammer et al. [29] reported no correlation
between high physical work demands among pregnant
women and PTB or LBW in univariate analyses. None-
theless, after controlling for numerous variables (age,
parity, complications during pregnancy, pre-pregnancy
body mass index (BMI), smoking, alcohol consumption,
marital status, planned pregnancy, contract work, work
hours per week, education, shift work, region of county
and job stress), high physical work demands became a sig-
nificant predictor of a birth weight ,2500 g [29]. In con-
trast, Vrijotte et al. [21] found a univariate association
between work physicality and birth weight but no multi-
variate association between any physical labour and SGA.
The authors suggested that adding maternal smoking into
the model might have disguised the association between
physical workload and birth weight as those with higher
92 OCCUPATIONAL MEDICINE
physical workloads were also more likely to report being
a smoker. Even though both studies employed a large pro-
spective cohort design, differences could still be explained
by a number of factors, including controlling for different
confounding variables and a difference in the way that
physicality of work was assessed. Niedhammer et al.
used a single-item measure of perceived job physicality,
whereas Vrijotte et al. utilized a seven-item scale from
the Job Content Questionnaire. Saurel-Cubizolles et al.
[30] also did not find an association between job physi-
cality and PTB.
Increased manual labour also has been shown to be
associated with pre-eclampsia [31]. In a study of medical
personnel, those who reported moderate to high physical
activity levels at work were twice as likely to develop
severe pre-eclampsia, as compared to medical staff who
reported low levels of physical activity. No impact of phys-
ical activity was found on spontaneous abortion [32].
Interestingly, a study by Canivet et al. [33] indicated that
high physical labour can also be protective as individuals
with higher physical demands reported less colic among
their infants.
Researchers have also investigated the impact of long
work hours on foetal outcomes. It is noteworthy that the
definition of ‘long work hours’ has yet to be standardized,
resulting in contradictory evidence regarding the impact
of long work hours on foetal outcomes. Studies have
reported anywhere from a 43 g to an 80 g decrease in birth
weight due to increased work hours alone [20,21,34].
Despite finding a bivariate association between birth
weight and hours of work, this relationship was not signif-
icant after controlling for age, parity, complications dur-
ing pregnancy, pre-pregnancy BMI, smoking, alcohol
consumption, marital status, planned pregnancy, con-
tract work, work hours per week, education, shift work,
region of country and job stress [29]. This could be
explained by the variability in the degree to which the
job is also physically demanding over an extended period
of time. After combining long work hours and high phys-
ical job activity, Hatch et al. [20] found that decreases in
birth weight could increase to a 350 g loss on average.
Bryant and Love [32] found no impact of long working
hours on spontaneous abortion. Direct comparison of
studies examining ‘long work hours’ is challenging be-
cause each study operationally defined long work hours
differently. However, the trend suggests that work hours
at the highest levels (.40 h/week) are of greater signifi-
cance. That withstanding, reported decreases in birth
weight due to long hours alone were modest and were
unlikely to have a large impact on the overall health of
the infant.
Few studies have examined how altering the physical
environment could impact pregnant women and health
outcomes. Pregnant women tend to spend more time
at the workplace in bent positions to compensate for
their changing body postures [35]. To reduce the need
for increased bending, Paul and Frings-Dresen [36]
recommend altering the height of surfaces, such as coun-
tertops and desks, to accommodate the temporarily al-
tered body anatomy of pregnant women and to reduce
the risks of excessive bending. On the other hand, an
ergonomic modification to the job environment does
not seem to have a preferential impact on pregnant
women regarding forearm support among computer
workers [37]. Overall, the exploration into the impact
of potential adaptation of the built environment has
received little attention, which may be attributed to the
relatively small window of pregnancy, as compared to
the longer work life span.
Downloaded from https://academic.oup.com/occmed/article/62/2/88/1480061 by guest on 30 May 2022
Chemical exposures
Certain work activities place women in contact with
chemicals that have been flagged as potentially harmful
to a pregnancy. Some of these chemicals or chemical com-
binations, such as second-hand tobacco smoke, have been
well studied in diverse populations. Studies that have spe-
cifically examined the effects of work-related second-
hand smoke inhalation have concluded that there is no
association between work inhalation and date of delivery
[38], birth weight [38,39], lactation onset [38] and prob-
lems with breastfeeding [38]. These findings suggest that
the amount of second-hand smoke inhalation at work-
place may be below the threshold necessary to cause
foetal abnormalities.
Beyond second-hand tobacco smoke, the potential
impact of chemical exposure in the workplace on preg-
nancy has been insufficiently studied. One study
found that acute exposures to carbon monoxide are
linked to foetal death, functional alterations and anatom-
ical malformations [40]. Stillbirth has also been found
to be more common among women who work in
metal–electrical–chemical industries and women exposed
to low levels of pesticides and germicides [41]. Another
study that investigated the impact of ‘waste’ anaesthetic
gas (i.e. gas that seeps into the airspace) among veterinar-
ians found no increased risk of major foetal malforma-
tions [42]. A study conducted in response to concerns
regarding nickel exposure found no impact on musculo-
skeletal disorders among women [21,43].
Several solvents have been shown to have an associa-
tion with SGA birth [44], including chlorophenols and
aromatic amines, used by leatherworkers [45]. Ahmed
et al. [44] suggest that exposure to solvents, even 3
months prior to conception, can be associated with
SGA risk. However, the same study detected no associa-
tion between solvent exposure and LBW or PTB. Addi-
tionally, a study by Testud et al. [46] found no relationship
with spontaneous abortion, major malformations, minor
malformations, LBW and gestational week at delivery.
A recent review on the effects of radiation on preg-
nancy found evidence to support risks related to ionizing

radiation, with the highest levels of exposure associated
with spontaneous abortion, foetal growth restriction,
mental retardation and cancer [47]. However, levels of
radiation among veterinarians did not show elevated risk
for major foetal malformations [42]. This could be due to
a low level of radiation exposure. Williams and Fletcher
[47] found little to no impact on foetal health due to acute
exposures of radiation ,0.05 Gy (5 rad). Exposures rang-
ing from 0.05 to 0.50 Gy (5–50 rads) could result in in-
creased likelihood of negative foetal outcomes. However,
acute exposures .0.50 Gy (50 rads) are most concerning.
The review also suggested that the risks of ionizing radi-
ation exposure are contingent upon period of foetal devel-
opment, with the greatest risk occurring between 2 and
7 weeks after conception [47].
Biological exposures
Exposure to biological agents is another area of concern
for maternal and infant health. In developed countries,
cytomegalovirus is the leading infectious cause of foetal
anomalies [48]. Women working in childcare or as nurses
are most at risk of cytomegalovirus exposure and contrac-
tion [48]. This is largely because toddlers ,30 months
shed cytomegalovirus through saliva and urine. Harger
et al. [49] found that 17% of pregnant women without
immunity acquired the parvovirus during pregnancy.
New parvovirus infection is a concern as it has been linked
with foetal death; however, among women exposed to
parvovirus during pregnancy, contraction was not signif-
icantly associated with occupation but rather having
a child in the home under age 18 years [49]. Overall, chil-
dren have been identified as a major vector for biological
exposures [48].
Psychosocial impacts
Although the role of stress in the workplace in pregnancy
has been well examined, previous research has produced
inconsistent findings. Landsbergis et al. [50] indicate that
women in positions with low levels of decision latitude
and low complexity are at higher risk for gestational
hypertension compared to those with greater power, even
after controlling for educational achievement and per
capita income. Spinillo et al. [31] found lower levels of
pre-eclampsia among clerical workers than unemployed
women. Salaija and Swaminathan [51] found greater
levels of state and trait anxiety among employed pregnant
women, as opposed to unemployed pregnant women.
However, DeJoseph [52] found no significant differences
among homemakers, part-time workers and full-time
workers with regards to state and trait anxiety or
depression.
Studies examining the relationship between job strain
and infant morbidity outcomes have also yielded mixed
results. High levels of job strain have been linked to de-
H. M. SALIHU ET AL.: PREGNANCY IN THE WORKPLACE 93
creased birth weight and SGA [21]. However, studies
have also established that there is no link between job
strain and LBW [29], SGA [29], PTB [29] or spontane-
ous abortion [53]. Despite these conflicting findings,
the literature does suggest that pregnancy is a source of
maternal stress.
The concept of role strain during pregnancy is also an
area of public health concern. Role strain occurs when
one’s social roles are in conflict, either with one another
or with one’s personal desires. When women become
pregnant, they must add the role of ‘mother’ to their
pre-existing role of ‘employee’ or ‘professional’ [54,55].
At times, these roles may conflict. Integration of these
Downloaded from https://academic.oup.com/occmed/article/62/2/88/1480061 by guest on 30 May 2022
two roles is one of the most significant challenges preg-
nant women face in the workplace [55]. Greenberg
et al. [55] documented the internal role clarification
among pregnant women through a qualitative study of
their experiences as pregnant women in the workplace.
Several themes emerged, including questioning profes-
sional legitimacy, balancing the degrees of importance
each role takes and how pregnancy impacts professional
aspirations. Many women felt that they needed to chal-
lenge common beliefs that pregnancy indicates a lack
of dedication, ambition and competency. However, many
women also scale back career aspirations after pregnancy
due to the increased value of the role of the mother and
family in their lives.
Other studies have substantiated the pervasiveness of
negative perceptions of pregnant women. It is commonly
believed that the pregnant employee is not invested and
instead serves as a liability and burden [12,55,56]. Col-
leagues suggest that a pregnancy adds stress to work re-
lationships [54]. Employees who were more positive
about pregnancy in the workplace tend to be women be-
tween the ages of 26 and 45 years [56]. Additionally, col-
leagues with previous positive experiences with pregnant
co-workers bear a more favourable disposition [56]. How-
ever, these dispositions may depend upon the type of em-
ployment. For example, individuals in university settings
are more inclined to view pregnancy favourably than
those in manufacturing settings [56].
To fight common misperceptions, pregnant women
employ numerous strategies to reaffirm their role as ‘pro-
fessionals’. Many women refuse special accommodations
or extra time off to avoid being tagged as lazy or uncom-
mitted [55]. This is reinforced through data regarding job
reassignment. Although many women are eligible for job
reassignment during pregnancy, very few assert this right
[12]. Another strategy employed by pregnant women is to
avoid conversations about pregnancy with co-workers
and superiors until later in the pregnancy after ascertain-
ing potential responses [55]. The delay might also be stra-
tegic around pay raises or promotions. This often requires
a delicate juggling of doctors’ appointments before or
after work or taking time off under the guise of some other
excuse [55]. After a pregnancy is known among
94 OCCUPATIONAL MEDICINE
colleagues, women often take measures to purposively
shift conversations from pregnancy-related topics to
work-related issues [55]. This can be challenging, as
many pregnant women indicate a shift in conversational
norms during pregnancy, as colleagues become more in-
formal and more personal regarding conversations.
Social support of pregnant women plays a large role in
the workplace. Women who perceive employers and supe-
riors as supportive are more likely to return to work after
childbirth. This reduces the risk to employers regarding
loss in skill and training. Similarly, businesses that plan
for and proactively approach pregnancy in the workplace
show lower rates of quitting and greater ease of shifting
workloads in the event of a pregnancy, which increases
productivity and decreases losses [12]. A negative atti-
tude in the workplace regarding pregnancy may also con-
tribute to job dissatisfaction, which is associated with an
increase in preterm delivery [28].
Discussion
In general, we observed that the risks to the foetus due to
work conditions tend to be minimal. Employment during
pregnancy is protective for SGA among black women
[57] and is protective for other foetal complications, such
as pre-eclampsia [31]. Evidence suggests that a job that is
satisfying does not add a significant amount of stress that
translates into negative foetal outcomes [21,28,29,53].
Role strain can be a cause of concern among some
employed women [54,55].
Previous research has indicated that the first trimester
of pregnancy represents the most vulnerable period for
women [58]. Occupational medicine (OM) clinics may
play an important role in addressing health issues unique
to pregnant women in the workplace by conducting early
assessments of workplace hazards and risks for pregnant
women. Unfortunately, OM clinics have been largely
unsuccessful at engaging female employees during the
early stages of pregnancy [59,60]. In a study of women
working with chemicals, radiation and noise, Von Busch
et al. [59] found that the average gestational age at pre-
sentation to a mandatory, free, convenient institutionally
promoted occupational health assessment was 7.5 weeks.
Despite the availability of a well-supported risk assess-
ment programme, women still remained exposed to envi-
ronmental work hazards at a critical time of foetal
development due to late presentation [59]. However,
mandatory institutionally supported risk assessments
show better participation than voluntary programmes.
The average gestational age among women who present
for voluntary occupational safety consultations is 10.9
weeks, .3 weeks later than mandatory screenings [60].
As early intervention is necessary to prevent detrimental
foetal outcomes, strategies must be established to
intervene at an earlier time point.
Pregnant women use more sick leave overall [61],
which may be the result of not having timely risk assess-
ments and avoiding reassignments of duties during preg-
nancy. In a case study of Danish hospitals, pregnant
women took an average of 6 days of sick leave/month
in comparison to non-pregnant women who took about
one [62]. Additionally, more than half of pregnant em-
ployees were on sick leave for 10–20% of their scheduled
time [62]. This can result in loss of productivity and in-
creased workplace stress as colleagues have to assume
additional responsibilities. However, studies suggest that,
if job reassignment is needed and received by pregnant
woman, reliance on sick leave decreases [63]. As individ-
Downloaded from https://academic.oup.com/occmed/article/62/2/88/1480061 by guest on 30 May 2022
uals with the most physically demanding jobs tend to use
sick leave more frequently [62], job reassignment may
present a means to reduce frequent absenteeism among
pregnant women.
We found that many of the physical and psychosocial
challenges experienced during pregnancy occur within
the first few weeks after conception. Consequently, it is
important to address pregnancy in the workplace before
it occurs. Preconception care is a strategy recommended
by the Centres for Disease Control and Prevention to pro-
vide health promotion, screening and interventions for
women of reproductive age to reduce risks that could
potentially affect future pregnancies [59]. As preconcep-
tion care encompasses the identification and modification
of personal behaviours and psychosocial risks, as well as
environmental exposures, the investigation of workplace
conditions that could possibly have deleterious effects on
pregnancy, and ultimately, maternal and infant outcomes
are an important part of this strategy.
It is recommended that occupational risk assessments
be conducted as part of regular preventive visits and pre-
pregnancy check-ups, and occupational physicians have
an important role in this regard. These assessments
may be addressed with an employee’s personal health care
provider, as well as through OM clinics. Within these
assessments, duties and environmental exposures within
the workplace should be considered. This is especially im-
portant among women in high-risk positions, such as
those exposed to radiation, solvents and chemicals, due
to the potential risks for foetal and infant morbidities.
Although manual labour and physically demanding jobs
do not pose a substantial risk to foetal health in and of
themselves, it is important that the combination of high
physicality and other factors, such as long work hours or
high job strain, is assessed. A moderate temporary reduc-
tion in job physicality may promote improved maternal
and foetal health. Women with a history of pregnancy
complications should receive additional attention.
Overall, for these preventive efforts to be successful,
an organizational culture that supports women and
pregnancy is necessary to alleviate any fears of negative
consequences in the workplace [12,55]. The issue of
pregnancy needs to be addressed proactively with an

emphasis on combating stereotypes of pregnant women
as incompetent or uncommitted. This organizational
change needs to occur on a systemic level, with the leader-
ship and support of supervisors and administrators.
The impact of work culture can have profound impli-
cations for maternal psychosocial health and intentions to
return to work after childbirth. As women constitute
a growing segment of the workforce and an increasing
proportion of individuals with advanced educational
training, a culture that embraces women and pregnancy
provides additional social support and increased job
satisfaction. This translates to lower levels of institutional
loss with regards to talent and experience as women are
then more likely to return to work after childbirth [12].
Additionally, the establishment of a ‘family friendly’ work
environment can lead to cost savings in hiring and train-
ing [12]. Organizations that appropriately plan for preg-
nancy have enhanced employee retention and are able to
more effectively integrate women of childbearing years
into the workforce [12]. It is important that occupational
health care workers and especially OM physicians play
a major role in promoting these positive attitudes towards
pregnant women within the work environment as part of
the overall strategy to minimize the burden of strain and
psychosocial stressors in the workplace.
Recommendations
The quality and amount of data collected on pregnancy in
the workplace varies by topic area and there is a lack of
uniformity of outcomes and measures, which makes it dif-
ficult to compare findings across studies. Legal issues
were largely examined through commissioned studies
at the national level. These studies were generally descrip-
tive in nature and did not assess the probability of negative
outcomes. Future studies examining the legal issues
should employ a prospective design to understand the
consequences of pregnancy discrimination in the work-
place. Furthermore, assessments of workplace policies
that address discrimination, as well as risk screenings,
should be conducted to yield further information regard-
ing beneficial interventions and practices. Some studies
regarding maternal and child health outcomes were
inconclusive. Studies examining physical exposures of
bending, standing, lifting, physicality of work, etc. tended
to utilize a prospective cohort and case–control
approaches. Findings of no association were not due to
lack of statistical power as many of these studies included
large national populations. Many of the studies that
reported inconclusive findings were actually systematic
reviews on specific topic areas. Therefore, the quality
of studies included in each topic area reviewed varied con-
siderably. However, studies examining the psychosocial
impacts of employment on pregnancy tended to be small
in size. This is not to suggest the quality of the data is in-
ferior; however, to have more stable and precise estimates,
H. M. SALIHU ET AL.: PREGNANCY IN THE WORKPLACE 95
Suggestions for Future Research
• Longitudinal studies of women’s career trajectory after
experiencing discrimination at work due to pregnancy.
• Assessments of workplace policies that address
pregnancy discrimination and risk screenings.
• Large scale, longitudinal studies of the psychosocial
impact of pregnancy in the workforce.
Figure 1. Suggestions for future research.
Downloaded from https://academic.oup.com/occmed/article/62/2/88/1480061 by guest on 30 May 2022
future research should explore psychosocial aspects of
pregnancy during employment based on larger and more
diverse sampling strategies (Figure 1).
Funding
This study was funded by a grant from the Flight Attendant
Medical Research Institute (FAMRI: 024008, Principal Inves-
tigator: Hamisu M. Salihu, MD, PhD). The funding agency did
not play any role in any aspect of the study.
Conflicts of interest
None declared.
References
1. European Agency for Safety and Health at Work. Women
and Health at Work. http://osha.europa.eu/en/priority_
groups/gender/index_html (2 January 2011, date last
accessed).
2. United States Department of Labor. Quick Stats on Women
Workers, 2009. 2009. http://www.dol.gov/wb/stats/main.htm
(2 January 2011, date last accessed).
3. Office for National Statistics. Women in the Labour Market:
Impact of Downturn. 2009. http://www.statistics.gov.uk/cci/
nugget.asp?id52145 (2 January 2010, date last accessed).
4. U.S. Equal Opportunity Commision. Facts About Pregnancy
Discrimination. 2008. http://www.eeoc.gov/facts/fs-preg.
html (2 January 2011, date last accessed).
5. United States Department of Labor. Fact Sheet #28: The
Family and Medical Leave Act of 1993. 2010. http://www.dol.
gov/whd/regs/compliance/whdfs28.htm (2 January 2011,
date last accessed).
6. Human Resources and Skills Development Canada. Labour:
Maternity Leave. 2007. http://www.hrsdc.gc.ca/eng/lp/spila/
wlb/wfp/11Maternity_Leave.shtml (19 February 2011, date
last accessed).
7. Department for Work and Pensions. NI17A—A Guide
for Maternity Benefits. 2010. http://www.dwp.gov.uk/
publications/specialist%2Dguides/technical%2Dguidance/
ni17a%2Da%2Dguide%2Dto%2Dmaternity/ (24 January
2011, date last accessed).
96 OCCUPATIONAL MEDICINE
8. The Department of Business Enterprise and Regulatory Re-
form. Pregnancy and Work: What You Need to Know as an Em-
ployee. 2009. http://www.direct.gov.uk/prod_consum_
dg/groups/dg_digitalassets/@dg/@en/@employ/documents/
digitalasset/dg_078787.pdf (19 February 2011, date last
accessed).
9. Euro Info Centre and London Chamber of Commerce
and Industry. EU Employment Law. 2006. http://www.
londonchamber.co.uk/DocImages/1154.pdf (24 January
2011, date last accessed).
10. European Agency for Safety and Health at Work. Protection
of Pregnant Workers and Workers Who Have Recently
Given Birth or Are Breastfeeding. 2008. http://europa.eu/
legislation_summaries/employment_and_social_policy/health
_hygiene_safety_at_work/c10914_en.htm (21 January 2011,
date last accessed).
11. Johnson T. Maternity Leave and Employment Patterns of First
Time Mothers: 1961–2003. Washington DC: US Census
Bureau, 2008.
12. Equal Opportunity Commission. Tip of the Iceberg: Interim
Report of the EOC’s Investigation Into Discrimination Against
New and Expectant Mothers in the Workplace. London:
European Union, 2004.
13. National Partnership for Women and Families. The Preg-
nancy Discrimination Act: Where We Stand 30 Years Later.
2008. http://www.nationalpartnership.org/site/DocServer/
Pregnancy_Discrimination_Act_-_Where_We_Stand_30_
Years_L.pdf?docID54281 (27 January 2011, date last
accessed).
14. Bragger JD, Kutcher E, Morgan J, Firth P. The effects
of the structured interview on reducing biases against
pregnant job applicants. Sex Roles 2002;46:215–226.
15. Simpson JL. Are physical activity and employment
related to preterm birth and low birth weight? Am J
Obstet Gynecol 1993;168:1231–1238.
16. Domingues MR, Matijasevich A, Barros AJD. Physical
activity and preterm birth: a literature review. Sports Med
2009;39:961–975.
17. Dunning K, LeMasters G, Levin L, Bhattacharya A,
Alterman T, Lordo K. Falls in workers during pregnancy:
risk factors, job hazards, and high risk occupations. Am
J Ind Med 2003;44:664–672.
18. Schiff MA. Pregnancy outcomes following hospitalisation
for a fall in Washington State from 1987 to 2004*. BJOG
2008;115:1648–1654.
19. El Kady D, Gilbert WM, Anderson J, Danielsen B,
Towner D, Smith LH. Trauma during pregnancy: an anal-
ysis of maternal and fetal outcomes in a large population.
Am J Obstet Gynecol 2004;190:1661–1668.
20. Hatch M, Ji BT, Shu XO, Susser M. Do standing, lifting,
climbing, or long hours of work during pregnancy
have an effect on fetal growth? Epidemiology 1997;8:
530–536.
21. Vrijkotte TG, van der Wal MF, van Eijsden M, Bonsel GJ.
First-trimester working conditions and birthweight: a pro-
spective cohort study. Am J Public Health 2009;99:
1409–1416.
22. Bonzini M, Coggon D, Godfrey K, Inskip H, Crozier S,
Palmer KT. Occupational physical activities, working hours
and outcome of pregnancy: findings from the Southampton
Women’s Survey. Occup Environ Med 2009;66:685–690.
23. Klebanoff MA, Shiono PH, Carey JC. The effect of physical
activity during pregnancy on preterm delivery and birth
weight. Am J Obstet Gynecol 1990;163:1450–1456(5 Pt 1).
24. Fenster L, Hubbard AE, Windham GC, Waller KO,
Swan SH. A prospective study of work-related physical exer-
tion and spontaneous abortion. Epidemiology 1997;8:66–74.
25. Henriksen TB, Hedegaard M, Secher NJ, Wilcox AJ. Stand-
ing at work and preterm delivery. Br J Obstet Gynaecol
1995;102:198–206.
26. Magann EF, Evans SF, Chauhan SP et al. The effects of
standing, lifting and noise exposure on preterm birth,
growth restriction, and perinatal death in healthy low-risk
working military women. J Matern Fetal Neonatal Med
2005;18:155–162.
27. Berkowitz GS. Employment-related physical activity and
Downloaded from https://academic.oup.com/occmed/article/62/2/88/1480061 by guest on 30 May 2022
pregnancy outcome. J Am Med Womens Assoc. 1995;50:
167–169, 174.
28. Henrich W, Schmider A, Fuchs I, Schmidt F,
Dudenhausen JW. The effects of working conditions and
antenatal leave for the risk of premature birth in Berlin. Arch
Gynecol Obstet 2003;269:37–39.
29. Niedhammer I, O’Mahony D, Daly S, Morrison JJ,
Kelleher CC. Occupational predictors of pregnancy out-
comes in Irish working women in the Lifeways cohort.
BJOG 2009;116:943–952.
30. Saurel-Cubizolles MJ, Subtil D, Kaminski M. Is preterm
delivery still related to physical working conditions in preg-
nancy? J Epidemiol Community Health 1991;45:29–34.
31. Spinillo A, Capuzzo E, Colonna L, Piazzi G, Nicola S,
Baltaro F. The effect of work activity in pregnancy on the
risk of severe preeclampsia. Aust N Z J Obstet Gynaecol
1995;35:380–385.
32. Bryant HE, Love EJ. Effect of employment and its correlates
on spontaneous abortion risk. Soc Sci Med 1991;33:
795–800.
33. Canivet C, Ostergren PO, Jakobsson I, Hagander B. Higher
risk of colic in infants of nonmanual employee mothers with
a demanding work situation in pregnancy. Int J Behav Med
2004;11:37–47.
34. Jansen PW, Tiemeier H, Verhulst FC et al. Employment sta-
tus and the risk of pregnancy complications: the Generation
R Study. Occup Environ Med 2010;67:387–394.
35. Paul JA, Frings-Dresen MH. Standing working posture
compared in pregnant and non-pregnant conditions. Ergo-
nomics 1994;37:1563–1575.
36. Paul JA, Frings-Dresen MH, Salle HJ, Rozendal RH. Preg-
nant women and working surface height and working sur-
face areas for standing manual work. Appl Ergon 1995;26:
129–133.
37. Slot T, Charpentier K, Dumas G, Delisle A, Leger A,
Plamondon A. Evaluation of forearm support provided
by the Workplace Board on perceived tension, comfort
and productivity in pregnant and non-pregnant computer
users. Work 2009;34:67–77.
38. Wdowiak A, Wiktor H, Wdowiak L. Maternal passive
smoking during pregnancy and neonatal health. Ann Agric
Environ Med 2009;16:309–312.
39. Hegaard HK, Kjaergaard H, Moller LF, Wachmann H,
Ottesen B. The effect of environmental tobacco smoke
during pregnancy on birth weight. Acta Obstet Gynecol Scand
2006;85:675–681.

40. Norman CA, Halton DM. Is carbon monoxide a workplace
teratogen? A review and evaluation of the literature. Ann
Occup Hyg 1990;34:335–347.
41. Goulet L, Theriault G. Stillbirth and chemical exposure of
pregnant workers. Scand J Work Environ Health 1991;17:
25–31.
42. Shuhaiber S, Einarson A, Radde IC, Sarkar M, Koren G.
A prospective-controlled study of pregnant veterinary staff
exposed to inhaled anesthetics and x-rays. Int J Occup Med
Environ Health 2002;15:363–373.
43. Vaktskjold A, Talykova LV, Chashchin VP, Odland JO,
Nieboer E. Maternal nickel exposure and congenital mus-
culoskeletal defects. Am J Ind Med 2008;51:825–833.
44. Ahmed P, Jaakkola JJ. Exposure to organic solvents and
adverse pregnancy outcomes. Hum Reprod 2007;22:
2751–2757.
45. Seidler A, Raum E, Arabin B, Hellenbrand W, Walter U,
Schwartz FW. Maternal occupational exposure to chemical
substances and the risk of infants small-for-gestational-age.
Am J Ind Med 1999;36:213–222.
46. Testud F, D’Amico A, Lambert-Chhum R, Garayt C,
Descotes J. Pregnancy outcome after risk assessment of
occupational exposure to organic solvents: a prospective
cohort study. Reprod Toxicol 2010;30:409–413.
47. Williams PM, Fletcher S. Health effects of prenatal radiation
exposure. Am Fam Physician 2010;82:488–493.
48. Harvey J, Dennis CL. Hygiene interventions for prevention
of cytomegalovirus infection among childbearing women:
systematic review. J Adv Nurs 2008;63:440–450.
49. Harger JH, Adler SP, Koch WC, Harger GF. Prospective
evaluation of 618 pregnant women exposed to
parvovirus B19: risks and symptoms. Obstet Gynecol
1998;91:413–420.
50. Landsbergis PA, Hatch MC. Psychosocial work stress
and pregnancy-induced hypertension. Epidemiology 1996;7:
346–351.
51. Sailaja BV, Swaminathan VD. Working and nonworking
pregnant women on state and trait anxiety. Psychol Stud
1992;37:173–177.
H. M. SALIHU ET AL.: PREGNANCY IN THE WORKPLACE 97
52. DeJoseph JF. Work, pregnancy, and distress. Work Stress
1992;6:379–383.
53. Fenster L, Schaefer C, Mathur A et al. Psychologic stress in
the workplace and spontaneous abortion. Am J Epidemiol
1995;142:1176–1183.
54. Tinsley JA. Pregnancy of the early-career psychiatrist.
Psychiatr Serv 2000;51:105–110.
55. Greenberg D, Ladge J, Clair J. Negotiating pregnancy at
work: public and private conflicts. Negot Conflict Manag
Res 2009;2:42–56.
56. Pattison HM, Gross H, Cast C. Pregnancy and employ-
ment: the perceptions and beliefs of fellow workers. J Reprod
Infant Psychol 1997;15:303–313.
57. Poerksen A, Petitti DB. Employment and low birth weight
in Black women. Soc Sci Med 1991;33:1281–1286.
Downloaded from https://academic.oup.com/occmed/article/62/2/88/1480061 by guest on 30 May 2022
58. Centers for Disease Control and Prevention. Recommenda-
tions to improve preconception health and health care—
United States: a report of the CDC/ATSDR Preconception
Care Work Group and the Select Panel on Preconception
Care. MMWR Recomm Rep 2006;55:1–23.
59. Von Busch TA, Frazier LM, Sigler SJ, Molgaard CA.
Feasibility of maternity protection in early pregnancy. Int
J Occup Environ Health 2002;8:328–331.
60. Frazier LM, Jones TL. Managing patients with concerns
about workplace reproductive hazards. J Am Med Womens
Assoc 2000;55:80–105–83.
61. Alexanderson K, Sydsjo A, Hensing G, Sydsjo G,
Carstensen J. Impact of pregnancy on gender differences
in sickness absence. Scand J Soc Med 1996;24:
169–176.
62. Kaerlev L, Jacobsen LB, Olsen J, Bonde JP. Long-term sick
leave and its risk factors during pregnancy among Danish
hospital employees. Scand J Public Health 2004;32:
111–117.
63. Kristensen P, Nordhagen R, Wergeland E, Bjerkedal T.
Job adjustment and absence from work in mid-
pregnancy in the Norwegian Mother and Child
Cohort Study (MoBa). Occup Environ Med 2008;65:
560–566.