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May 3, 2012

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Health care – Baby on board

With more women in the workforce than ever and a birth rate higher than it was ten years ago, ensuring the health and well-being of pregnant employees and new mothers is an important task for practitioners. Dr Chris Ide provides an overview of the main issues to address.

In times past, pregnant women were urged to ‘eat for two,’ the rationale being that it was necessary to replace the iron, calcium and other minerals, proteins, etc. that were used to build up the growing baby and prevent long-term depletion of the woman’s own body stores. This notion has long since been debunked but should a woman decide to remain at work during pregnancy, then her employer will be expected to ‘be safe for two’, since the duty of care owed by the employer to the mother-to-be is also extended to her unborn child. Should the mother decide to return to work after delivery, then this duty also applies for up to six months, or for the duration of breast-feeding, whichever is the longer.

This is an issue for health and safety practitioners that has evolved very rapidly. When the authors of Fitness for work1 were revising the publication, it coincided with the 25th anniversary of the Faculty of Occupational Medicine (FOM), and they noted: “When the FOM was established, the first IVF baby, Louise Brown, was just a year old; by now, she is a working woman. Over the same time, the UK female employment rate rose from 42 to 70 per cent.”

Also over the same time, the traditional manufacturing industry has declined but, although there has been a concomitant reduction in time-honoured toxic hazards, what has taken manufacturing’s place is not necessarily hazard-free and, based on my own experiences, I suspect that there may be toxic hazards aplenty in the small-enterprise sector of craft and artisan workshops. But that’s another story.

Baby monitor

The safety advisor needs to look at the workplace and direct their thoughts along two main channels. Firstly, what are the potential hazards in this workplace for someone who is pregnant? This leads to two subsequent lines of consideration: is it possible to make an accurate assessment of the risk arising from this, and what is the most effective way in which both mother and unborn child(ren) can be protected?

Secondly, how may various symptoms, changes and complications of pregnancy impact on work, and – following on from this – what modifications need to be made in order for the employee to continue to discharge at least the core aspects of her duties?

The hazards can be categorised according to the traditional physical/chemical/ biological/ergonomic classification, examples of which include:

  • Physical

Ionising radiation: In 1895, Wilhelm Roentgen announced his discovery of X-rays. Within about 15 years, just about all their harmful effects had been described and, since then, a great deal of research has accumulated to define more precisely the levels of exposure associated with these harms, as well as those associated with other forms of radiation, such as alpha and beta particles. The foetus grows rapidly, so is very susceptible to radiation damage, its precise effects depending on the stage of pregnancy at which the exposure occurs.

Thus, within the first fortnight of conception, lethal damage can occur to chromosomes. Up to eight weeks, when the major organ systems are being laid down, congenital malformations arise. Between eight and 15 weeks, the brain is developing rapidly, so exposures at this point may give rise to reduction in intelligence and mental retardation. Then there is the increased lifetime risk of cancer. The Ionising Radiation Regulations 1999 and associated Code of Practice can help the safety advisor on these issues.2

Non-ionising radiation: When I began my career in occupational medicine, back in 1983, there was considerable concern about reported clusters of miscarriages among women who worked with visual display units, then a very new technology. I remember that foil tabards and various screen protection devices were being vigorously marketed, at least until properly organised and conducted studies demonstrated that, at the levels of exposure involved, the incidence of miscarriage was usually no greater than would have been expected elsewhere. Radiofrequency radiation is unlikely to be a hazard, as long as there is no significant tissue-heating effect.

Noise: The abdominal wall, womb and amniotic fluid will generally attenuate most external noise, although low frequencies may be transmitted to the foetus, and damage hearing. Nonetheless, this would only seem to be a problem if the ambient noise levels are high (more than 110 dBA),3 a level which, if sustained for any significant length of time, would likely adversely affect the mother’s hearing as well.

  • Chemical

Lead: Lead toxicity is well known and widely studied. It is also the subject of specific legislation, the Control of Lead at Work Regulations 2002,4 which refer to ‘women of reproductive capacity’. The Regulations place restrictions on exposure of the latter to processes that have the potential to generate high levels of lead and sets lower blood levels of lead at which health surveillance, action and suspension are triggered. Once pregnancy is declared, the Regulations specify that the woman should be removed from any exposure likely to be significant.

Therapeutic drugs: The risks to fertility of patients taking drugs used in cancer treatment is well known. Other medicines, such as anti-convulsants, produce foetal deformities, and antibiotics like tetracyclines can stain bones and teeth. There is a need for caution in extrapolating from results in patients to workers who manufacture the drug but, when risk-assessing, it will be necessary to gain information on length of exposure and types of protection used to minimise absorption of the material concerned. Some idea of the potential for harm may come from looking for various risk codes on hazard data sheets – in particular, symbols like R60 and R62, which imply the possibility of fertility problems, and R64, which suggests that breast-fed babies may be harmed.

  • Biological

The best-known hazards to pregnant women and their unborn children arise from infections with germs that cause zoonoses (infectious diseases of animals potentially transmissible to humans), such as chlamydiosis, listeriosis and Q-fever, which arise from farm animals and unpasteurised dairy products and uncooked meat. These can cause miscarriage and serious – even fatal – maternal illness. Meticulous attention to cleanliness and hand hygiene offers the best protection.

Don’t forget the possibility of human-to-human transmission of more mundane infectious viral disease, such as rubella or chicken-pox, which can cause severe malformations in the unborn, particularly if contracted in the earlier stages of pregnancy. The availability of the measles/mumps/rubella vaccine as a part of the routine schedule of childhood immunisation has gone a long way to reducing the incidence of some of these problems, but women working in a patient-contact type of job would be wise to ensure that they are actually immune and take steps to remedy the matter if they are not.

  • Ergonomic

Exertion: Various researchers have suggested that strenuous work during pregnancy is potentially harmful, insofar as it is associated with an increase in the numbers of infants who are born either prematurely (before 37 weeks), or small for their dates (less than 5.5 lbs).5 Babies who fall into either or both of these categories contribute disproportionately to peri- and neonatal mortality (deaths within the first week and month after birth) and subsequent disability.

Yet for mothers who are generally well, exercise is considered beneficial.6 I suppose that one way of reconciling these views is to remember that exercise is generally voluntary, and that if out running, or adopting particular yoga postures, it is usually possible to stop if the discomfort becomes unbearable. This may be less easy for those working on a paced production line, or others, like musicians, who have to adopt, or hold exaggerated postures.

  • All change

Doctors – even obstetricians – have to be reminded from time to time that pregnancy is not a disease, that pregnant women should not have their lives hedged around with restrictions and should be allowed to live as normal a life as possible, which includes going to work. Many women feel very well. However, as the pregnancy progresses, changes – albeit normal – occur and need to be managed. For example, there may be an increased need to pass urine as the womb grows and takes up space, compressing the bladder. The woman may become easily nauseated, and this sensation may be triggered by strong scents.

Later in the pregnancy, the increasing bulk of the womb, the tendency for the spinal and pelvic ligaments to become more lax, and for oedema (tissue fluid) to accumulate, especially in the lower limbs, means sustained running becomes a problem. Should significant amounts of this fluid also build up in the hands and wrists, this can trigger the development of carpal tunnel syndrome.

Lifting and carrying, particularly of bulky items, become problematic, and changes in the woman’s centre of gravity can increase the likelihood of slips, trips and falls, as well as entry to, and egress from, confined spaces. It may also impact on the layout of work stations, and provision of personal protective equipment. Lastly, the woman may experience reduced stamina and so may need to take more breaks.

The conscientious safety advisor will already have taken steps to ensure that the workplace is safe, so far as is reasonably practicable, from the point of view of all the employees who work there. The benefits of any further modification of the safety aspects of the workplace can only begin to be realised once the employer, and the safety advisor, become aware of the pregnancy. This depends entirely on the employee, who may believe that there are certain advantages to formally advising the employer at the earliest opportunity. However, others may choose to postpone the announcement, particularly if they feel they might be financially disadvantaged.

Nonetheless, once notified of pregnancy, the safety assessment will have to be reviewed and, where necessary, revised with the needs of the pregnant employee in mind. This will be most effectively achieved if the employee is involved in the assessment review, and any further revision required as the pregnancy progresses – particularly if the employee regards the pregnancy as very precious, or if complications develop during the pregnancy. Should this be the case, it would be helpful to involve the occupational-health service, should the organisation have access to one. If not, then consent will have to be obtained to contact the employee’s GP, obstetrician, or midwife.

The safety advisor’s task may be made a bit less onerous if any risk assessments made in relation to ordinary employees are revised regularly, especially if the nature of the work changes, and the question: “What if someone becomes pregnant?” is additionally incorporated. The HSE publishes useful guidance in this respect.7
The decision to return to work after delivery usually hinges on the interaction of economic factors and the desire (or not) to continue with – or further develop – a career, as well as the availability of childcare facilities, whether provided by the employer, local authority, or relatives. Although the woman may have expressed keenness to return, this may be held up by a variety of factors, including complications related to wound healing, which might occur as a result of tears or surgical procedures, such as Caesarean sections or forceps delivery.

Mental-health problems can vary in severity – from ‘baby blues’, which are surprisingly common, to psychotic depression, which is, fortunately, very rare. Most of these problems are satisfactorily sorted via a combination of help from relatives, neighbours and the primary-care team – although people at work, whether line managers, fellow employees, or both, can also help simply by remaining in touch, but without overwhelming the person concerned. Finally, the new-born baby may not thrive, and may develop health problems of its own, so the mother may feel that the infant needs her more than her work does.

As noted earlier, the legislation that protects women during pregnancy also extends to any breast-feeding period. There is no doubt that breast milk is the best food for young babies, and some mothers continue to breast-feed for many months. If the mother needs to breast-feed, or express milk, while at work, suitable facilities will have to be provided for her, and she will need to be protected from exposure to, and uptake of, substances that might contaminate breast tissue and be transferred to the baby. Generally speaking, these will often be highly fat-soluble compounds, such as organic solvents and PCBs, or any other material that carries the risk phrase ‘R64’.

Pregnancy is an exciting phase of life. By being prepared to listen to employees and their managers, and offer appropriate advice, the safety advisor has the opportunity to make a potentially vulnerable worker feel – and be – safer, and to help create a workplace environment to which she would wish to return.

1    Palmer KT, Cox RAF and Brown I – eds (2007): Fitness for Work – the medical aspects (4th Ed), Ch.20: Women at work – Coomber SEL, Harris PA, Faculty of Occupational Medicine/Oxford University Press
3    Gerhardt KJ, Abrams RM (2000): ‘Foetal exposure to sound and vibro-acoustic stimulation’, in J Perinatol 2000, 20;8:S21-30.
4    Control of Lead at Work Regulations 2002, Approved Code of Practice and guidance, ISBN 978 0 7176 2565 6, HSE Books
5    Mozurkewich EL, Luke B, Avni M, Wolf FM (2000): ‘Working conditions and adverse pregnancy outcomes: a meta-analysis’, in Obstet Gynaecol 2000, 95;4; 623:635
6    Both MI, Overvest MA, Wildhagen MF, Golding J, Wildshut HI (2010): ‘The association of daily physical activity and birth outcome: a population-based cohort study’ in Eur J Epidemiol 2010,25;6:421-429

Dr Chris Ide is an occupational physician and regular contributor to SHP.

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