Clinical guidelines for occupational lifting in pregnancy: evidence summary and provisional recommendations

Do current policies reflect current evidence on the relationship between occupational risks and preterm birth, and are they consistent? A policy content analysis

OBJECTIVES

Preterm birth is a leading cause of neonatal mortality and the second-leading cause of death among children under five worldwide. Recent systematic reviews have demonstrated an increased risk of preterm birth in women exposed to workplace physical and psychosocial risks during pregnancy. The extent to which this evidence is reflected in policy remains unclear. This study aimed to determine the extent to which current policies reflect the current evidence regarding the association between occupational risks and preterm birth.

STUDY DESIGN

Policy content analysis.

METHODS

This study used a three-step search strategy: searching electronic databases (Embase and Scopus), policy databases (Overton, Dimension, and Google Advanced), and websites of global and national agencies/organisations focused on occupational or women's health policies. Data were analysed through descriptive and interpretive content analyses. Eligible documents were publicly available in full text, published from 2000 onwards by credible sources, and written in English.

RESULTS

Thirteen eligible policy documents were identified. Of these, eight concluded that the evidence for the relationship between occupational risks and preterm birth was inconclusive. The remaining five documents report that occupational risks may be associated with an increased risk of preterm birth. Nine documents offered recommendations to address this risk. These included four recommending job redesign, two information/education, and three a combination of job redesign, job transfer, information/education, and changes to workplace policy. Three were developed by a multidisciplinary stakeholder group, six by a multidisciplinary clinical group, and four by unidisciplinary clinicians.

CONCLUSIONS

Most current policies partially reflect the current evidence on the relationship between occupational risks and preterm birth. Development of most policy documents did not use rigorous methods and did not involve multidisciplinary stakeholder groups. There is an urgent need for the development of evidence-based policies grounded in robust research methods.

Consensus-Driven Recommendations to Support Physician Pregnancy, Adoption, Surrogacy, Parental Leave, and Lactation in Emergency Medicine

The emergency department clinical environment is unique, and guidelines for promoting supportive and equitable workplace cultures ensure success and longevity for pregnant persons and parents in emergency medicine. There is paucity, variability, and dissatisfaction with current parental (historically referred to as maternity and paternity) leave policies. This paper describes the development of consensus-derived recommendations to serve as a framework for emergency departments across the country for incorporating family-friendly policies. Policies that foster a family-inclusive workplace by allowing for professional advancement without sacrificing personal values regardless of sex, gender, and gender identity are critical for emergency medicine recruitment and retention.

Physical job demands in pregnancy and associated musculoskeletal health and employment outcomes: a systematic review

OBJECTIVE

A decline in musculoskeletal health during pregnancy is an underappreciated adverse outcome of pregnancy that can have immediate and long-term health consequences. High physical job demands are known risk factors for nontraumatic musculoskeletal disorders in the general working population. Evidence from meta-analyses suggest that occupational lifting and prolonged standing during pregnancy may increase risk of adverse pregnancy outcomes. This systematic review examined associations between occupational lifting or postural load in pregnancy and associated musculoskeletal disorders and related sequalae.

DATA SOURCES

Five electronic databases (Medline, Embase, CINAHL, NIOSHTIC-2, and Ergonomic Abstracts) were searched from 1990 to July 2022 for studies in any language. A Web of Science snowball search was performed in December 2022. Reference lists were manually reviewed.

STUDY ELIGIBILITY CRITERIA

Eligible studies reported associations between occupational lifting or postural load and musculoskeletal health or sequelae (eg, employment outcomes) among pregnant and postpartum workers.

METHODS

Data were extracted using a customized form to document study and sample characteristics; and details of exposures, outcomes, covariates, and analyses. Investigators independently assessed study quality for 7 risk-of-bias domains and overall utility, with discrepant ratings resolved through discussion. A narrative synthesis was conducted due to heterogeneity.

RESULTS

Sixteen studies (11 cohort studies, 2 nested case-control studies, and 3 cross-sectional studies) from 8 countries were included (N=142,320 pregnant and N=1744 postpartum workers). Limited but consistent evidence with variable quality ratings, ranging from critical concern to high, suggests that pregnant workers exposed to heavy lifting (usually defined as ≥22 lbs or ≥10 kg) may be at increased risk of functionally limiting pelvic girdle pain and antenatal leave. Moreover, reports of dose-response relationships suggest graded risk levels according to lifting frequency, ranging from 21% to 45% for pelvic girdle pain and 58% to 202% for antenatal leave. Limited but consistent evidence also suggests that postural load increases the risk of employment cessation.

CONCLUSION

Limited but consistent evidence suggests that pregnant workers exposed to heavy lifting and postural load are at increased risk of pelvic girdle pain and employment cessation. Job accommodations to reduce exposure levels may promote safe sustainable employment for pregnant workers.

Social Determinants of Premature Birth

Social determinants of health have received increasing attention in public health, leading to increased understanding of how social factors-individual and contextual-shape the health of the mother and infant. However, racial differences in birth outcomes persist, with incomplete explanation for the widening disparity. Here, we highlight the social determinants of preterm birth, with special attention to the social experiences among African American women, which are likely attributed to structural racism and discrimination throughout life.

The impact of procedural activities on musculoskeletal pain experienced by pregnant surgeons

BACKGROUND

Two-thirds of surgeons report work-related musculoskeletal disorders (WRMD). There is limited data on WRMD symptoms experienced by pregnant surgeons.

METHODS

We distributed an electronic survey via personal contacts to attending and trainee surgeons across six academic institutions to assess the impact of procedural activities and surgical ergonomics (SE) on WRMD symptoms during pregnancy.

RESULTS

Fifty-three respondents were currently or had been pregnant while clinically active, representing 93 total pregnancies. 94.7% reported that symptoms were exacerbated by workplace activities during pregnancy and 13.2% took unplanned time off work as a result. Beyond 24 weeks of pregnancy, 89.2% of respondents continued to operate/perform procedures, 81.7% worked >24-h shifts and 69.9% performed repetitive lifting >50 pounds. No respondents were aware of any institutional pregnancy-specific SE policies.

CONCLUSIONS

Procedural activities can exacerbate pain symptoms for the pregnant surgeon. SE best practices during pregnancy warrant further attention.

Racial and Ethnic Disparities in Phthalate Exposure and Preterm Birth: A Pooled Study of Sixteen U.S. Cohorts

BACKGROUND

Phthalate exposures are ubiquitous during pregnancy and may contribute to racial and ethnic disparities in preterm birth.

OBJECTIVES

We investigated race and ethnicity in the relationship between biomarkers of phthalate exposure and preterm birth by examining: a) how hypothetical reductions in racial and ethnic disparities in phthalate metabolites might reduce the probability of preterm birth; and b) exposure-response models stratified by race and ethnicity.

METHODS

We pooled individual-level data on 6,045 pregnancies from 16 U.S. cohorts. We investigated covariate-adjusted differences in nine urinary phthalate metabolite concentrations by race and ethnicity [non-Hispanic White (White, 43%), non-Hispanic Black (Black, 13%), Hispanic/Latina (38%), and Asian/Pacific Islander (3%)]. Using g-computation, we estimated changes in the probability of preterm birth under hypothetical interventions to eliminate disparities in levels of urinary phthalate metabolites by proportionally lowering average concentrations in Black and Hispanic/Latina participants to be approximately equal to the averages in White participants. We also used race and ethnicity-stratified logistic regression to characterize associations between phthalate metabolites and preterm birth.

RESULTS

In comparison with concentrations among White participants, adjusted mean phthalate metabolite concentrations were consistently higher among Black and Hispanic/Latina participants by 23%-148% and 4%-94%, respectively. Asian/Pacific Islander participants had metabolite levels that were similar to those of White participants. Hypothetical interventions to reduce disparities in metabolite mixtures were associated with lower probabilities of preterm birth for Black [13% relative reduction; 95% confidence interval (CI): - 34 % , 8.6%] and Hispanic/Latina (9% relative reduction; 95% CI: - 19 % , 0.8%) participants. Odds ratios for preterm birth in association with phthalate metabolites demonstrated heterogeneity by race and ethnicity for two individual metabolites (mono-n-butyl and monoisobutyl phthalate), with positive associations that were larger in magnitude observed among Black or Hispanic/Latina participants.

CONCLUSIONS

Phthalate metabolite concentrations differed substantially by race and ethnicity. Our results show hypothetical interventions to reduce population-level racial and ethnic disparities in biomarkers of phthalate exposure could potentially reduce the probability of preterm birth. https://doi.org/10.1289/EHP12831.

Public health guidelines for physical activity during pregnancy from around the world: a scoping review

BACKGROUND AND OBJECTIVE

Despite the known health benefits of physical activity (PA), pregnancy is a time of marked decline in PA levels. To provide women with reliable and trustworthy information, and to encourage greater participation in PA during pregnancy, many governments have developed guidelines for PA during pregnancy. Our aim was to synthesise the most recent public health guidelines on PA during pregnancy from different countries in order to understand the nature and extent of advice that is available.

DESIGN

Scoping review.

DATA SOURCES

Search of the grey literature, direct contact with international experts, screening of relevant academic literature and citation searching.

ELIGIBILITY CRITERIA

Public health guidelines developed or endorsed by government departments published since 2010.

RESULTS

Our search located 30 eligible guidelines, published in 11 different languages. There is remarkable concordance in the advice offered. For women with uncomplicated pregnancy, guidelines recommend: 150-300 min/week of moderate intensity aerobic activity; pelvic floor and muscle strengthening exercises; modification of some exercises (eg, supine position); and provide lists of warning signs to cease activity (eg, persistent dizziness, vaginal bleeding) and activities that should be avoided (eg, if high risk of falling/collision). Few guidelines offer specific advice for highly active women (eg, athletes), or trimester-specific or culturally specific considerations.

CONCLUSIONS

This review provides a summary of public health recommendations for PA during pregnancy around the world. The challenge is now to ensure that all who provide healthcare for women understand the guidelines and encourage safe participation in PA during pregnancy.

Ergonomic Considerations in Urologic Surgery

PURPOSE OF REVIEW

This paper aims to discuss the various work-related musculoskeletal disorders (WRMDs) among urologists and provide an overview of the latest recommendations to improve awareness of ergonomic principles that can be applied in the operating room, with special consideration of challenges faced during pregnancy.

RECENT FINDINGS

Urologists suffer from a large burden of WRMDs. The main drivers of pain associated with the various surgical approaches include repetitive movements, static and awkward body positions, and the use of burdensome equipment. Pregnant surgeons are at an even greater risk of WRMDs and face high rates of pregnancy complications. Laparoscopy, endoscopy, robot-assisted surgeries, and open surgeries present unique ergonomic challenges for the practicing urologist. Proper posture and equipment use, optimal operating room setup, intraoperative stretching breaks, and an emphasis on teaching ergonomic principles can reduce the risk of WRMDs. Surgeons are also at increased risk of WRMDs during pregnancy but may continue to operate while taking measures to limit physical exertion and fatigue. Improving awareness of and incorporating ergonomic principles early in a urologist's career may reduce the risk of injury and improve operative performance and longevity.

Maximizing Recovery in the Postpartum Period: A Timeline for Rehabilitation from Pregnancy through Return to Sport

Increased participation and duration in sport has become commonplace for women with their involvement often including the transition to motherhood in the peak of their athletic careers. No rehabilitation models that assess the full spectrum of pregnancy to postpartum have been developed for women to assist in safe exercise progressions that reduce postpartum symptoms and optimize performance during the return to full activity. Referral to physical therapy both in the prenatal and postnatal period is currently not considered standard of care to reduce prevalence of symptoms such as musculoskeletal pain, diastasis recti, and pelvic floor dysfunction which may ultimately interfere with physical activity and performance. This commentary presents a timeline and suggested progression for exercise participation to improve awareness of the musculoskeletal changes that occur after labor and delivery. The concepts covered may increase the understanding of how to manage pregnant and postpartum athletes from a musculoskeletal perspective and serve as a starting point for establishing appropriate and guided rehabilitation for safe return to sport after childbirth.

Water carrying in hills of Nepal–associations with women’s musculoskeletal disorders, uterine prolapse, and spontaneous abortions

More than a third of women in Nepal have to carry water from source to home to satisfy their families’ daily needs. A cross-sectional study was carried out in a hilly area in Nepal to assess water-carrying practices and their association with women’s health. Quantitative interviews were conducted with 1001 women of reproductive age and were complemented with health surveys carried out by health professionals and structured observations of water carrying. Multivariate mixed logistic regression models were used to assess the associations between water-carrying-related risk factors and health issues for women. Around 46% of women faced considerably increased to excessive physical stress due to water carrying during the dry season. Women suffered from a disproportionately high prevalence of back pain (61%), with about 18% of this pain being horrible to excruciating; pain in the knees (34%); uterine prolapse (11.3%); and at least one spontaneous abortion (9%). The risk category of water carrying was significantly associated with uterine prolapse (OR = 1.44, 95%CI = 1.12–1.85, p = 0.031) and pain in the hips (OR = 1.69, 95%CI = 1.27–2.26, p<0.001). Receiving help with water carrying during pregnancy and during the first three months after delivery was associated with reduced odds ratios for uterine prolapse (OR = 0.10, 95% CI = 0.01–0.87, p = 0.037), and strong back pain (OR = 0.32, 95% CI = 0.12–0.87, p = 0.026). Improvements to water supply infrastructure and the promotion of social support for carrying water during pregnancy and after delivery are recommended to reduce water-carrying-related health risks.

Musculoskeletal discomfort in veterinary healthcare professions

BACKGROUND

Veterinarians appear to be at risk for work-related musculoskeletal discomfort (MSD), based on surveys conducted outside the US.

OBJECTIVE

This study provides new information about MSD prevalence in veterinarians and veterinary technicians in the US.

METHODS

Cross-sectional survey and observation.

RESULTS

A survey of 56 veterinarians and 38 veterinary technicians in Ohio found 12-month prevalence of MSD exceeded 60% in the neck, low back, and legs/feet. More than 85% of participants reported that work activities exacerbated discomfort in at least one region. Less than one-third of participants reported symptom-related lost work time. Personal and work-related burnout scores were higher for veterinary technicians, compared with veterinarians. Nine percent of observed work activities performed by veterinarians and 43% performed by veterinary technicians were rated high or very high risk.

CONCLUSIONS

High prevalence of MSD and low lost work time suggest many individuals are working in pain. Increased adoption of existing ergonomics solutions (equipment and process changes), in addition to further investigation of unmet needs, could improve working conditions and reduce musculoskeletal stress in veterinary health professions.

Understanding safe water-carrying practices during pregnancy and postpartum: A mixed-methods study in Nepal

Daily carrying of heavy loads of domestic water, especially during pregnancy and postpartum, bears a threat to maternal health in low‐income countries. Using an extended health action process approach (HAPA), we examined women's reasons for and psychosocial determinants of safe water‐carrying during pregnancy and postpartum. In a mixed‐methods study, trained local interviewers conducted 1001 quantitative interviews with women of reproductive age (n = 921 analyzed) and 21 qualitative interviews with women of reproductive age, in‐laws, and spouses in rural Nepal. We analyzed the quantitative data with generalized estimating equations to model the HAPA‐based psychosocial determinants of avoiding water‐carrying during pregnancy and postpartum. Subjective perspectives were investigated with thematic analysis. Outcome expectancies (B = 0.24), self‐efficacy (B = 0.20), and injunctive norms (B = 0.23) were significantly associated with the intention to avoid water‐carrying. Self‐efficacy (B = 0.36) and instrumental support (B = 0.05) are related to behavior (all p < 0.05). Women explained water‐carrying during pregnancy by a lack of family support, a shift of health decision‐making power to in‐laws, and low behavioral control. Overall, the necessity of water, family decision‐making structures, and low support make it difficult for women to discontinue water‐carrying. Additionally to infrastructural improvements, behavioral interventions may increase women's self‐efficacy for safe water‐carrying (e.g. reducing weight) and social support.

Shoulder and elbow requirements during sagittal reach as a result of changing anthropometry throughout pregnancy

During pregnancy, anthropometric and physiological changes can result in difficulty reaching for and lifting everyday objects. The aims of this study were to determine the changes in sagittal plane anterior reach space (SPARS) and shoulder/elbow strength requirements throughout pregnancy. Seventeen participants were tested through a longitudinal observational cohort study between 16 and 36 weeks gestation in four-week intervals. A 25% decrease in SPARS was observed at the L3-4 torso height. Combined with arm mass increases, shoulder and elbow moment requirements at the minimum and maximum static reach distances significantly increased. However, inverse dynamics analysis determined that mass gains in the arm alone only minimally impact dynamic shoulder moments. Additionally, torso flexion increases throughout pregnancy demonstrates that women are attempting to compensate for decreased SPARS, possibly indicating the additional perceptual importance of reach space in accommodations for pregnant workers.

Ergonomic Stressors Among Pregnant Healthcare Workers: Impact on pregnancy outcomes and recommended safety practices

Workplace environment can have a considerable impact on the physical, psychological and maternal health of pregnant healthcare workers. This article aimed to summarise the impact of work-related ergonomic stressors on pregnancy outcomes for healthcare workers, along with potential interventions to resolve these stressors. A narrative review analysis using the Pearl Growing Strategy was conducted between February 2019 and June 2020 to identify English-language articles published between 2000 and 2020. A total of 89 studies were identified from the SCOPUS (Elsevier, Amsterdam, Netherlands), MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA) databases and Google Scholar (Google LLC, Menlo Park, California, USA). The results indicated that poor work-related ergonomics had detrimental effects on pregnancy outcomes, resulting in spontaneous abortions, preterm delivery, low birth weight babies and infertility. Policymakers and employers should conduct ergonomic assessments and implement appropriate practices to ensure the safety of pregnant healthcare workers.

Physical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804

Exercise, defined as physical activity consisting of planned, structured, and repetitive bodily movements done to improve one or more components of physical fitness, is an essential element of a healthy lifestyle, and obstetrician-gynecologists and other obstetric care providers should encourage their patients to continue or to commence exercise as an important component of optimal health. Women who habitually engaged in vigorous-intensity aerobic activity or who were physically active before pregnancy can continue these activities during pregnancy and the postpartum period. Observational studies of women who exercise during pregnancy have shown benefits such as decreased gestational diabetes mellitus, cesarean birth and operative vaginal delivery, and postpartum recovery time. Physical activity also can be an essential factor in the prevention of depressive disorders of women in the postpartum period. Physical activity and exercise in pregnancy are associated with minimal risks and have been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements. In the absence of obstetric or medical complications or contraindications, physical activity in pregnancy is safe and desirable, and pregnant women should be encouraged to continue or to initiate safe physical activities. This document has been revised to incorporate recent evidence regarding the benefits and risks of physical activity and exercise during pregnancy and the postpartum period.

The impact of occupational activities during pregnancy on pregnancy outcomes: a systematic review and metaanalysis

OBJECTIVE

Data: An increasing number of studies suggest that exposure to physically demanding work during pregnancy could be associated with increased risks of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. The purpose of this study was to examine the influence of occupational activities during pregnancy on maternal and fetal health outcomes.

STUDY

Studies of all designs (except case studies and reviews) that contained information on the relevant population (women who engaged in paid work during pregnancy), occupational exposures (heavy lifting, prolonged standing, prolonged walking, prolonged bending, and heavy physical workload), comparator (no exposure to the listed physical work demands), and outcomes (preterm birth, low birthweight, small for gestational age, miscarriage, gestational hypertension, preeclampsia, gestational diabetes mellitus, stillbirth, and intrauterine growth restriction) were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Five electronic databases and 3 gray literature sources were searched up to March 15, 2019.

RESULTS

Eighty observational studies (N=853,149) were included. Low-to-very low certainty evidence revealed that lifting objects ≥11 kg was associated with an increased odds ratio of miscarriage (odds ratio, 1.31; 95% confidence interval, 1.08-1.58; I²=79%), and preeclampsia (odds ratio, 1.35; 95% confidence interval, 1.07-1.71; I²=0%). Lifting objects for a combined weight of ≥100 kg per day was associated with an increased odds of preterm delivery (odds ratio, 1.31; 95% confidence interval, 1.11-1.56; I²=0%) and having a low birthweight neonate (odds ratio, 2.08; 95% confidence interval, 1.06-4.11; I²=73%). Prolonged standing was associated with increased odds of preterm delivery (odds ratio, 1.11; 95% confidence interval, 1.02-1.22; I²=30%) and having a small-for-gestational-age neonate (odds ratio, 1.17; 95% confidence interval, 1.01-1.35; I²=41%). A heavy physical workload was associated with increased odds of preterm delivery (odds ratio, 1.23; 95% confidence interval, 1.07-1.41; I²=32%) and having a low birthweight neonate (odds ratio, 1.79; 95% confidence interval, 1.11-2.87; I²=87%). All other associations were not statistically significant. Dose-response analysis showed women stand for >2.5 hours per day (vs no standing) had a 10% increase in the odds of having a preterm delivery.

CONCLUSION

Physically demanding work during pregnancy is associated with an increased risk of adverse pregnancy outcomes.

Reproductive toxic agents in work environments and related cases in Korea

There has been a growing concern and subsequent interest surrounding numerous reproductive toxic agents found in various working and non-working environments. Meanwhile, there have been many efforts in medical fields such as toxicology and epidemiology applying experimental studies to elucidate reproductive toxic agents' characterization and health effects. However, there remains insufficient research data and inadequate evidence in humans. Adverse reproductive outcomes vary from transient, moderate health effects to severely detrimental consequences, such as permanent infertility or childhood cancer of one's offspring. Furthermore, upon exposure to toxic agents, the latent period before reproductive health effects are observed is relatively short compared to other occupational diseases (e.g., occupational cancer); instant action is required once exposure to reproductive toxic agents is detected. Therefore, it is very important for workers and healthcare professionals to know about the reproductive toxic agents they are likely to be exposed to. In this review, we discuss the general epidemiology of reproductive health in Korea, and the information regarding these reproductive toxic agents.

ACOG Committee Opinion No. 733: Employment Considerations During Pregnancy and the Postpartum Period

In the United States, it is common for women, including mothers and pregnant women, to work outside the home. Working during pregnancy is generally safe. For those in high-risk occupations or with medically complicated pregnancies, work accommodations often can allow for continued safe employment. The major employment issues concerning pregnant women include pregnancy-related discrimination, work accommodations that allow continued employment, job-protected leave, and wage replacement while on leave. Workplace discrimination related to being pregnant and pregnancy-related harassment, including discrimination in the hiring process, is prohibited by federal and state law. There is no federal law guaranteeing comprehensive accommodations for pregnant and postpartum workers. Current federal and state laws provide protection for some pregnant women, but not others, because of eligibility requirements and state-by-state differences. By writing appropriate notes to employers, obstetrician-gynecologists and other obstetric care providers can be instrumental in obtaining accommodations for their patients who are able to continue working. Accommodations that allow a woman to keep working are the most reliable way to guarantee pay, benefits, and job protection. Obstetrician-gynecologists and other obstetric care providers also can assist pregnant women and their partners by providing them with information and resources that might help them better understand their employment rights. However, in cases for which potential job discrimination has occurred, accommodations are denied, extended medical leave is necessary, or when other complex employment questions arise, legal assistance should be obtained.

A Liftless Intervention to Prevent Preterm Birth and Low Birthweight Among Pregnant Ghanaian Women: Protocol of a Stepped-Wedge Cluster Randomized Controlled Trial

Background

Preterm birth (PTB) is a leading cause of infant morbidity and mortality worldwide. Every year, 20 million babies are born with low birthweight (LBW), about 96% of which occur in low-income countries. Despite the associated dangers, in about 40%-50% of PTB and LBW cases, the causes remain unexplained. Existing evidence is inconclusive as to whether occupational physical activities such as heavy lifting are implicated. African women bear the transport burden of accessing basic needs for their families. Ghana’s PTB rate is 14.5%, whereas the global average is 9.6%. The proposed liftless intervention aims to decrease lifting exposure during pregnancy among Ghanaian women. We hypothesize that a reduction in heavy lifting among pregnant women in Ghana will increase gestational age and birthweight.

Objective

To investigate the effects of the liftless intervention on the incidence of PTB and LBW among pregnant Ghanaian women.

Methods

A cohort stepped-wedge cluster randomized controlled trial in 10 antenatal clinics will be carried out in Ghana. A total of 1000 pregnant participants will be recruited for a 60-week period. To be eligible, the participant should have a singleton pregnancy between 12 and 16 weeks gestation, be attending any of the 10 antenatal clinics, and be exposed to heavy lifting. All participants will receive standard antenatal care within the control phase; by random allocation, two clusters will transit into the intervention phase. The midwife-led 3-component liftless intervention consists of health education, a take-home reminder card mimicking the colors of a traffic light, and a shopping voucher. The primary outcome are gestational ages of <28, 28-32, and 33-37 weeks. The secondary outcomes are LBW (preterm LBW, term but LBW, and postterm), compliance, prevalence of low back and pelvic pain, and premature uterine contractions. Study midwives and participants will not be blinded to the treatment allocation.

Results

Permission to conduct the study at all 10 antenatal clinics has been granted by the Ghana Health Service. Application for funding to begin the trial is ongoing. Findings from the main trial are expected to be published by the end of 2019.

Conclusions

To the best of our knowledge, there has been no randomized trial of this nature in Ghana. Minimizing heavy lifting among pregnant African women can reduce the soaring rates of PTB and LBW. The findings will increase the knowledge of the prevention of PTB and LBW worldwide.

Trial Registration

Pan African Clinical Trial Register (PACTR201602001301205); http://apps.who.int/trialsearch/ Trial2.aspx?TrialID=PACTR201602001301205 (Archived by WebCite at http://www.webcitation.org/71TCYkHzu)

Registered Report Identifier

RR1-10.2196/10095

Lifting and pregnancy outcomes: feasibility of a randomized controlled trial

Background

The highest incidence of preterm birth (18%) occurs in Africa but the causes are largely unknown. Some studies have reported adverse effects of maternal physical exertion on birth outcomes. A randomized controlled trial (RCT) is proposed to determine the effectiveness of an intervention reducing lifting and carrying in pregnant women in reducing preterm birth and low birthweight.

Aims

To test the feasibility and acceptability of the proposed lift-less intervention RCT.

Methods

We recruited pregnant women and midwives from antenatal clinics within the Greater Accra Region of Ghana. The midwives were trained to administer the intervention during a 5-week trial. Four intervention trial sessions were organized at weekly intervals.

Results

Seven pregnant women and six midwives participated. After piloting, we observed a reduction in participants' self-reported daily exposure to heavy lifting and carrying. The daily average frequency of lifting by a participant within the first seven days of the study was 3.5 (SD 1.7) with an estimated mean total weight of 41.1 kg (SD = 13.3 kg). This had decreased to 2.3 (SD = 1.0) and the amount to 13.4 kg (SD = 10.9) within the last seven days of the study.

Conclusions

The findings provide insight into the daily physical exertion experienced by pregnant women in Ghana. The lift-less intervention trial is feasible with modifications and has the potential to reduce excessive physical exertion among pregnant women in Ghana to improve birth outcomes.

Low back pain and causative movements in pregnancy: a prospective cohort study

Background

Low back pain (LBP) during pregnancy might be strongly related to posture and movements of the body, and its management is a clinically important issue. The purpose of this study was to investigate the activities related to LBP during pregnancy.

Methods

Participants included 275 women before 12 weeks of pregnancy. The women were evaluated at 12, 24, 30, and 36 weeks of pregnancy. The intensity of LBP was assessed using the Numerical Rating Scale (NRS). Movements related to LBP were investigated by free descriptive answers. Descriptive statistics were used to compile the movements that pregnant women thought induced LBP at each evaluation. Subsequently, a linear regression analysis was performed to evaluate the degree of association of certain movements with LBP using the data of participants who had LBP. The intensity of LBP (NRS score) was specified as the dependent variable, the movements that were related to pain were specified as the independent variables at the analysis. A significance threshold was set at 0.05.

Results

The final sample used in the analyses was 254, 249, 258, and 245 women at 12, 24, 30, and 36 weeks of pregnancy, respectively. There were 16 kinds of movements that induced LBP and all of them were daily activities rather than special movements that require extra task or effort. As pregnancy progressed, less number of participants attributed pain to a specific movement. At all evaluations, movements, especially sitting up, standing up from a chair, and tossing and turning were thought to be related to LBP. Furthermore, standing up from a chair and tossing and turning were significantly related to LBP throughout the pregnancy. In contrast, lying down and sitting up were significantly related to LBP but the relationship did not continue till late pregnancy.

Conclusions

Daily routine activity is related to LBP during pregnancy. These results suggest that recommendations for pregnant women about basic physical movements, such as ways of standing up that reduce the load on the body might be useful in the management of LBP.

Non-chemical Risk Assessment for Lifting and Low Back Pain Based on Bayesian Threshold Models

Background

Self-reported low back pain (LBP) has been evaluated in relation to material handling lifting tasks, but little research has focused on relating quantifiable stressors to LBP at the individual level. The National Institute for Occupational Safety and Health (NIOSH) Composite Lifting Index (CLI) has been used to quantify stressors for lifting tasks. A chemical exposure can be readily used as an exposure metric or stressor for chemical risk assessment (RA). Defining and quantifying lifting nonchemical stressors and related adverse responses is more difficult. Stressor–response models appropriate for CLI and LBP associations do not easily fit in common chemical RA modeling techniques (e.g., Benchmark Dose methods), so different approaches were tried.

Methods

This work used prospective data from 138 manufacturing workers to consider the linkage of the occupational stressor of material lifting to LBP. The final model used a Bayesian random threshold approach to estimate the probability of an increase in LBP as a threshold step function.

Results

Using maximal and mean CLI values, a significant increase in the probability of LBP for values above 1.5 was found.

Conclusion

A risk of LBP associated with CLI values > 1.5 existed in this worker population. The relevance for other populations requires further study.

Review of hazards to female reproductive health in veterinary practice

OBJECTIVE To review publications that address female reproductive health hazards in veterinary practice, summarize best practices to mitigate reproductive risks, and identify current knowledge gaps. DESIGN Systematized review. SAMPLE English-language articles describing chemical, biological, and physical hazards present in the veterinary workplace and associations with adverse reproductive outcomes or recommendations for minimizing risks to female reproductive health. PROCEDURES Searches of the CAB abstracts database were performed in July 2012 and in May 2015 with the following search terms: veterinarians AND occupational hazards and vets.id AND occupational hazards.sh. Searches of the PubMed database were conducted in November 2012 and in May 2015 with the following medical subject heading terms: occupational exposure AND veterinarians; anesthetics, inhalation/adverse effects AND veterinarians; risk factors AND pregnancy AND veterinarians; pregnancy outcome AND veterinarians; and animal technicians AND occupational exposure. Two additional PubMed searches were completed in January 2016 with the terms disinfectants/toxicity AND female AND fertility/drug effects and veterinarians/psychology AND stress, psychological. No date limits were applied to searches. RESULTS 4 sources supporting demographic trends in veterinary medicine and 118 resources reporting potential hazards to female reproductive health were identified. Reported hazards included exposure to anesthetic gases, radiation, antineoplastic drugs, and reproductive hormones; physically demanding work; prolonged standing; and zoonoses. CONCLUSIONS AND CLINICAL RELEVANCE Demographic information suggested that an increasing number of women of reproductive age will be exposed to chemical, biological, and physical hazards in veterinary practice. Information on reproductive health hazards and minimizing risk, with emphasis on developing a safety-focused work culture for all personnel, should be discussed starting in veterinary and veterinary technical schools and integrated into employee training.

"Will my work affect my pregnancy?" Resources for anticipating and answering patients' questions

BACKGROUND

Authoritative information on occupational reproductive hazards is scarce and complex because exposure levels vary, multiple exposures may be present, and the reproductive toxicity of many agents remains unknown. For these reasons, women's health providers may find it challenging to effectively address workplace reproductive health issues with their patients who are pregnant, breast-feeding, or considering pregnancy. Reproductive epidemiologists at the Centers for Disease Control and Prevention National Institute for Occupational Safety and Health answered >200 public requests for occupational reproductive health information during 2009 through 2013. The most frequent occupations represented were health care (41%) and laboratory work (18%). The most common requests for exposure information concerned solvents (14%), anesthetic gases (10%), formaldehyde (7%), infectious agents in laboratories (7%) or health care settings (7%), and physical agents (14%), including ionizing radiation (6%). Information for developing workplace policies or guidelines was sought by 12% of the requestors. Occupational exposure effects on breast-feeding were an increasing concern among working women. Based on information developed in response to these requestors, information is provided for discussing workplace exposures with patients, assessing potential workplace reproductive hazards, and helping patients determine the best options for safe work in pregnancy. Appendices provide resources to address specific occupational exposures, employee groups, personal protective equipment, breast-feeding, and workplace regulations regarding work and pregnancy. These tools can help identify those most at risk of occupational reproductive hazards and improve workers' reproductive health. The information can also be used to inform research priorities and assist the development of workplace reproductive health policies.

ACOG Committee Opinion No. 650: Physical Activity and Exercise During Pregnancy and the Postpartum Period

Physical activity in all stages of life maintains and improves cardiorespiratory fitness, reduces the risk of obesity and associated comorbidities, and results in greater longevity. Physical activity in pregnancy has minimal risks and has been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements. Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during, and after pregnancy. Obstetrician-gynecologists and other obstetric care providers should carefully evaluate women with medical or obstetric complications before making recommendations on physical activity participation during pregnancy. Although frequently prescribed, bed rest is only rarely indicated and, in most cases, allowing ambulation should be considered. Regular physical activity during pregnancy improves or maintains physical fitness, helps with weight management, reduces the risk of gestational diabetes in obese women, and enhances psychologic well-being. An exercise program that leads to an eventual goal of moderate-intensity exercise for at least 20-30 minutes per day on most or all days of the week should be developed with the patient and adjusted as medically indicated. Additional research is needed to study the effects of exercise on pregnancy-specific outcomes and to clarify the most effective behavioral counseling methods, and the optimal intensity and frequency of exercise. Similar work is needed to create an improved evidence base concerning the effects of occupational physical activity on maternal-fetal health.

Miscarriage among flight attendants

BACKGROUND

Cosmic radiation and circadian disruption are potential reproductive hazards for flight attendants.

METHODS

Flight attendants from 3 US airlines in 3 cities were interviewed for pregnancy histories and lifestyle, medical, and occupational covariates. We assessed cosmic radiation and circadian disruption from company records of 2 million individual flights. Using Cox regression models, we compared respondents (1) by levels of flight exposures and (2) to teachers from the same cities, to evaluate whether these exposures were associated with miscarriage.

RESULTS

Of 2654 women interviewed (2273 flight attendants and 381 teachers), 958 pregnancies among 764 women met study criteria. A hypothetical pregnant flight attendant with median first-trimester exposures flew 130 hours in 53 flight segments, crossed 34 time zones, and flew 15 hours during her home-base sleep hours (10 pm-8 am), incurring 0.13 mGy absorbed dose (0.36 mSv effective dose) of cosmic radiation. About 2% of flight attendant pregnancies were likely exposed to a solar particle event, but doses varied widely. Analyses suggested that cosmic radiation exposure of 0.1 mGy or more may be associated with increased risk of miscarriage in weeks 9-13 (odds ratio = 1.7 [95% confidence interval = 0.95-3.2]). Risk of a first-trimester miscarriage with 15 hours or more of flying during home-base sleep hours was increased (1.5 [1.1-2.2]), as was risk with high physical job demands (2.5 [1.5-4.2]). Miscarriage risk was not increased among flight attendants compared with teachers.

CONCLUSIONS

Miscarriage was associated with flight attendant work during sleep hours and high physical job demands and may be associated with cosmic radiation exposure.

Provisional recommended weight limits for manual lifting during pregnancy

OBJECTIVE

The National Institute for Occupational Safety and Health (NIOSH) Revised Lifting Equation (RNLE) was adapted to derive recommended weight limits (RWLs) for pregnant workers and to develop corresponding guidelines for clinicians.

BACKGROUND

In the past three decades there has been a large increase in the number of women employed outside the home and remaining in the workforce during pregnancy. Practical authoritative guidelines based on accumulated evidence are needed to inform allowable work activity levels for healthy pregnant workers.

METHOD

Empirically based lifting criteria established by NIOSH to reduce the risk of overexertion injuries in the general U.S. working population were evaluated for application to pregnant workers. Our evaluation included an extensive review of the literature linking occupational lifting to maternal and fetal health. Decision logic and supporting literature are presented, along with computational details.

RESULTS

Provisional RWLs for pregnant workers were derived from the RNLE, along with guidelines for clinicians. The guidelines advise against pregnant workers lifting below midshin and overhead.

CONCLUSION

Based on our review of the available evidence, we present lifting thresholds that most pregnant workers with uncomplicated pregnancies should be able to perform without increased risk of adverse maternal and fetal health consequences. Except for restrictions involving lifting from the floor and overhead, the provisional guidelines presented are compatible with NIOSH lifting recommendations adopted in the early 1990s for the general working population.

APPLICATION

Implementation of these provisional guidelines could protect millions of female workers in the workplace from fetal and maternal lifting-related health problems.